Provider Demographics
NPI:1699878215
Name:GLICK, AMBER LORRAINE (PTA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LORRAINE
Last Name:GLICK
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 1:6698 HWY 17 N
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501
Mailing Address - Country:US
Mailing Address - Phone:608-553-2814
Mailing Address - Fax:
Practice Address - Street 1:528 W PINE ST
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:715-477-1523
Practice Address - Fax:715-477-1524
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1237019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant