Provider Demographics
NPI:1124016407
Name:OCONTO PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:OCONTO PHYSICAL THERAPY, LLC
Other - Org Name:HAIGHT PAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-437-7246
Mailing Address - Street 1:300 N BROADWAY
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2702
Mailing Address - Country:US
Mailing Address - Phone:920-437-7246
Mailing Address - Fax:920-437-1511
Practice Address - Street 1:300 N BROADWAY
Practice Address - Street 2:SUITE 3C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2702
Practice Address - Country:US
Practice Address - Phone:920-437-7246
Practice Address - Fax:920-437-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1934225100000X
WI2368225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40422000Medicaid
WIDA7771OtherMEDICARE RR
WI40422000Medicaid