Provider Demographics
NPI:1336293448
Name:BANDHOLZ, GINA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:BANDHOLZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:WANKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1327 WINDY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:HUBERTUS
Mailing Address - State:WI
Mailing Address - Zip Code:53033-9302
Mailing Address - Country:US
Mailing Address - Phone:262-628-3608
Mailing Address - Fax:
Practice Address - Street 1:N112W17975 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-2425
Practice Address - Country:US
Practice Address - Phone:262-532-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4942-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336293448Medicaid
WI000386693Medicare ID - Type UnspecifiedPERSONAL ID#
WI1336293448Medicaid