Provider Demographics
NPI:1073607834
Name:BACKE, KIMBERLY ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BACKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:SIEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7001 S HOWELL AVE
Mailing Address - Street 2:800
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1407
Mailing Address - Country:US
Mailing Address - Phone:414-856-0303
Mailing Address - Fax:414-856-9991
Practice Address - Street 1:7001 S HOWELL AVE
Practice Address - Street 2:800
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1407
Practice Address - Country:US
Practice Address - Phone:414-856-0303
Practice Address - Fax:414-856-9991
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4735024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40385200Medicaid
WI834240001Medicare ID - Type Unspecified