Provider Demographics
NPI:1033533773
Name:VANBOGAERT, TIMOTHY PHILIP
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PHILIP
Last Name:VANBOGAERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3607
Mailing Address - Country:US
Mailing Address - Phone:630-542-4154
Mailing Address - Fax:
Practice Address - Street 1:9047 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-2808
Practice Address - Country:US
Practice Address - Phone:414-607-0910
Practice Address - Fax:414-607-0924
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2086-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant