Provider Demographics
NPI:1073718771
Name:LJN THERAPY, SC
Entity Type:Organization
Organization Name:LJN THERAPY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-453-0135
Mailing Address - Street 1:2345 N 114TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1225
Mailing Address - Country:US
Mailing Address - Phone:414-453-0135
Mailing Address - Fax:
Practice Address - Street 1:1404 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2238
Practice Address - Country:US
Practice Address - Phone:414-288-1757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40429500Medicaid
1326110859OtherINDIVIDUAL NPI
1326110859OtherINDIVIDUAL NPI
00001444Medicare ID - Type UnspecifiedGROUP PROVIDER #