Provider Demographics
NPI:1356330609
Name:LETSOM, WILLIAM H (PT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:H
Last Name:LETSOM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3522
Mailing Address - Country:US
Mailing Address - Phone:262-694-3977
Mailing Address - Fax:262-694-5648
Practice Address - Street 1:7201 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3522
Practice Address - Country:US
Practice Address - Phone:262-694-3977
Practice Address - Fax:262-694-5648
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1882-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41811000Medicaid
WI40189600Medicaid
WI41811000Medicaid