Provider Demographics
NPI:1093915472
Name:ANDERSON, DIANE ELIZABETH (PTA)
Entity Type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:ANDERSON
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 1:17085 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5523
Mailing Address - Country:US
Mailing Address - Phone:262-617-7748
Mailing Address - Fax:262-786-1087
Practice Address - Street 1:316 N MILWAUKEE ST STE 208
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5803
Practice Address - Country:US
Practice Address - Phone:414-615-0665
Practice Address - Fax:414-615-0667
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1329-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant