Provider Demographics
NPI:1083772529
Name:VAN DEWATER, EDWARD V (MPT CSCS)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:V
Last Name:VAN DEWATER
Suffix:
Gender:M
Credentials:MPT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6222 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3948
Mailing Address - Country:US
Mailing Address - Phone:262-884-6418
Mailing Address - Fax:262-884-6489
Practice Address - Street 1:6222 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3948
Practice Address - Country:US
Practice Address - Phone:262-884-6418
Practice Address - Fax:262-884-6489
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9822-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40407400Medicaid
WI9822-024OtherSTATE LICENSE NUMBER
WI40407400Medicaid