Provider Demographics
NPI:1376986786
Name:NEISIUS, TINA (PTA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:NEISIUS
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 1:5417 E BUSS RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525-8805
Mailing Address - Country:US
Mailing Address - Phone:608-365-2620
Mailing Address - Fax:
Practice Address - Street 1:709 MEADOW PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WI
Practice Address - Zip Code:53525-9777
Practice Address - Country:US
Practice Address - Phone:608-676-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI762-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI762-19OtherPTA LICENSURE