Provider Demographics
NPI:1114193885
Name:NULTY, SUSAN DEE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DEE
Last Name:NULTY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6735 W BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-3325
Mailing Address - Country:US
Mailing Address - Phone:414-354-3300
Mailing Address - Fax:414-354-7419
Practice Address - Street 1:6735 W BRADLEY RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-3325
Practice Address - Country:US
Practice Address - Phone:414-354-3300
Practice Address - Fax:414-354-7419
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI595019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40044400Medicaid