Provider Demographics
NPI:1164623062
Name:WYSOCKI, THERESA A (BE)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:A
Last Name:WYSOCKI
Suffix:
Gender:F
Credentials:BE
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:WYSOCKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BE
Mailing Address - Street 1:575 BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1322
Mailing Address - Country:US
Mailing Address - Phone:262-284-4235
Mailing Address - Fax:262-284-4235
Practice Address - Street 1:575 BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1322
Practice Address - Country:US
Practice Address - Phone:262-284-4235
Practice Address - Fax:262-284-4235
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIN.A.1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0176670001Medicare ID - Type UnspecifiedMEDICARE PROVIDER#