Provider Demographics
NPI:1235550781
Name:GEISELMAN, GREG (PTA)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:GEISELMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20932 BUCK RUN LN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-8677
Mailing Address - Country:US
Mailing Address - Phone:608-475-3620
Mailing Address - Fax:
Practice Address - Street 1:800 COMPASSION WAY
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1956
Practice Address - Country:US
Practice Address - Phone:608-930-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-01
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2055-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant