Provider Demographics
NPI:1245398536
Name:LEASE, BECKY J (PT)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:J
Last Name:LEASE
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 1:505 KELLER AVE S
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001
Mailing Address - Country:US
Mailing Address - Phone:715-268-6900
Mailing Address - Fax:715-268-6895
Practice Address - Street 1:505 KELLER AVE S
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-6900
Practice Address - Fax:715-268-6895
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6207024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40322600Medicaid
HP48014OtherHEALTH PARTNERS
318L9LEOtherBCBS OF MN
6406390OtherMEDICA INS