Provider Demographics
NPI:1215966908
Name:FLOCK, AMY BETH (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
Last Name:FLOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29632 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-5004
Mailing Address - Country:US
Mailing Address - Phone:414-640-0335
Mailing Address - Fax:
Practice Address - Street 1:955 MAIN ST STE CD
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1752
Practice Address - Country:US
Practice Address - Phone:262-662-9760
Practice Address - Fax:262-662-9761
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI348-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40437000Medicaid