Provider Demographics
NPI:1134297070
Name:POLISHINSKI, STACI CHRISTINE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:CHRISTINE
Last Name:POLISHINSKI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:STACI
Other - Middle Name:CHRISTINE
Other - Last Name:HEISLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:845 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6174
Mailing Address - Country:US
Mailing Address - Phone:920-322-0447
Mailing Address - Fax:920-322-1362
Practice Address - Street 1:845 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6174
Practice Address - Country:US
Practice Address - Phone:920-322-0447
Practice Address - Fax:920-322-1362
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI375019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40293200Medicaid