Provider Demographics
NPI:1124213871
Name:CONDON, SUE LYN (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:LYN
Last Name:CONDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:SUE
Other - Middle Name:LYN
Other - Last Name:BLAZEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:P.O. BOX 387
Mailing Address - Street 2:2817 NEW PINERY ROAD, SUITE 103
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53949
Mailing Address - Country:US
Mailing Address - Phone:608-745-6211
Mailing Address - Fax:608-745-6250
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-6211
Practice Address - Fax:608-745-6250
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40240700Medicaid