Provider Demographics
NPI:1013398288
Name:PERRY, DENISE RAE (PTA)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:RAE
Last Name:PERRY
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 1:400 N MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1857
Mailing Address - Country:US
Mailing Address - Phone:608-873-5651
Mailing Address - Fax:
Practice Address - Street 1:400 N MORRIS ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1857
Practice Address - Country:US
Practice Address - Phone:608-873-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-14
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2173-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant