Provider Demographics
NPI:1083990212
Name:DRIESSEN, MEGHAN R (PTA)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:R
Last Name:DRIESSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 HENNES CT
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1609 COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1629
Practice Address - Country:US
Practice Address - Phone:920-898-5627
Practice Address - Fax:920-898-1375
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1783-019225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner