Provider Demographics
NPI:1124222930
Name:WUTTKE, CYNTHIA L (PT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:WUTTKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3694 OLD 89 RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53114-1218
Mailing Address - Country:US
Mailing Address - Phone:262-724-4463
Mailing Address - Fax:
Practice Address - Street 1:300 MC CANNA PKWY
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-3622
Practice Address - Country:US
Practice Address - Phone:262-767-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3860-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist