Provider Demographics
NPI:1083830376
Name:SHUDA, DAWN (PT)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:SHUDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S84W32531 JERICHO RD
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9273
Mailing Address - Country:US
Mailing Address - Phone:262-363-9629
Mailing Address - Fax:
Practice Address - Street 1:1701 SHARP RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-5214
Practice Address - Country:US
Practice Address - Phone:262-534-7297
Practice Address - Fax:262-534-7257
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3320-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist