Provider Demographics
NPI:1003174855
Name:LASSELLE, CHERYL (DPT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:LASSELLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 N FANCHER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-2051
Mailing Address - Country:US
Mailing Address - Phone:262-886-1956
Mailing Address - Fax:
Practice Address - Street 1:2210 N FANCHER RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-2051
Practice Address - Country:US
Practice Address - Phone:262-886-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5876-24225100000X
TX1134039225100000X
CA19444225100000X
IL070.010640225100000X
KS11-01243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist