Provider Demographics
NPI:1376502773
Name:NISSENBAUM, DAVID MICHAEL (MPT MA LAT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:NISSENBAUM
Suffix:
Gender:M
Credentials:MPT MA LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CROSS PLAINS
Mailing Address - State:WI
Mailing Address - Zip Code:53528-9477
Mailing Address - Country:US
Mailing Address - Phone:608-413-0550
Mailing Address - Fax:608-413-0552
Practice Address - Street 1:1118 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CROSS PLAINS
Practice Address - State:WI
Practice Address - Zip Code:53528-9477
Practice Address - Country:US
Practice Address - Phone:608-413-0550
Practice Address - Fax:608-413-0552
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2090392255A2300X
WI6391024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer