Provider Demographics
NPI:1235222746
Name:M & M PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:M & M PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-571-9146
Mailing Address - Street 1:1333 COLLEGE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172
Mailing Address - Country:US
Mailing Address - Phone:414-571-9146
Mailing Address - Fax:414-571-9147
Practice Address - Street 1:1333 COLLEGE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172
Practice Address - Country:US
Practice Address - Phone:414-571-9146
Practice Address - Fax:414-571-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5437225100000X
WI5672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40355700Medicaid