Provider Demographics
NPI:1083681407
Name:NIEMUTH, PAUL E (PT,DSC,OCS,SCS,ATC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:NIEMUTH
Suffix:
Gender:M
Credentials:PT,DSC,OCS,SCS,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 52ND ST STE 240
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3423
Mailing Address - Country:US
Mailing Address - Phone:262-925-5000
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:112 ASH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1487
Practice Address - Country:US
Practice Address - Phone:715-635-2518
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1739225100000X
WI1811-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11363195OtherCAQH
WI1083681407Medicaid
WI11363195OtherCAQH