Provider Demographics
NPI:1003072992
Name:SWANSON, MARTHA J (PTA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:SWANSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:J
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1941 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-6904
Mailing Address - Country:US
Mailing Address - Phone:715-246-9553
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1509225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant