Provider Demographics
NPI:1346318151
Name:CASTELLANO, BRENDA KAYE (PTA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAYE
Last Name:CASTELLANO
Suffix:
Gender:F
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:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54484-0156
Mailing Address - Country:US
Mailing Address - Phone:715-687-2214
Mailing Address - Fax:
Practice Address - Street 1:225 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:WI
Practice Address - Zip Code:54484-0156
Practice Address - Country:US
Practice Address - Phone:715-687-2214
Practice Address - Fax:715-687-4716
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI967-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40305400Medicaid