Provider Demographics
NPI:1376873778
Name:SPANBAUER, LAURIE J (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:J
Last Name:SPANBAUER
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 1:877 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-2104
Mailing Address - Country:US
Mailing Address - Phone:715-748-5259
Mailing Address - Fax:
Practice Address - Street 1:440 WELLS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-1409
Practice Address - Country:US
Practice Address - Phone:715-389-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI685019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant