Healthcare Provider Details

I. General information

NPI: 1720304777
Provider Name (Legal Business Name): AMY J SORDAHL MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 MILL ST
NEW LONDON WI
54961-2155
US

IV. Provider business mailing address

N6044 SPRING CREEK RD
MANAWA WI
54949-9127
US

V. Phone/Fax

Practice location:
  • Phone: 920-531-2031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number6259
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: