Provider Demographics
NPI:1134647845
Name:BRAITHWAITE, MICHELLE SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUZANNE
Last Name:BRAITHWAITE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:SUZANNE
Other - Last Name:WANGROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1300 S GREEN BAY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4469
Mailing Address - Country:US
Mailing Address - Phone:262-898-3930
Mailing Address - Fax:262-898-3933
Practice Address - Street 1:2900 W OKLAHOMA AVE STE 518
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10400509-2401225100000X
WI14545-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100088859Medicaid