Provider Demographics
NPI:1154457604
Name:KREITER, MICHELLE M (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:KREITER
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:W314S8909 WIGWAM DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8887
Mailing Address - Country:US
Mailing Address - Phone:262-363-0823
Mailing Address - Fax:
Practice Address - Street 1:4214 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-4142
Practice Address - Country:US
Practice Address - Phone:262-554-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4328-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40201600Medicaid