Provider Demographics
NPI:1346258662
Name:WISSINK, JULIE ANN (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:WISSINK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:FREID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2257 EVENSON DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8776
Mailing Address - Country:US
Mailing Address - Phone:608-779-5145
Mailing Address - Fax:
Practice Address - Street 1:2600 WARD AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7424
Practice Address - Country:US
Practice Address - Phone:608-787-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9629-024225100000X
VA2305006020225100000X
MO102455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist