Provider Demographics
NPI:1407107162
Name:CASPERSON, HAZEL MARIE PATIAG (PT)
Entity Type:Individual
Prefix:
First Name:HAZEL MARIE
Middle Name:PATIAG
Last Name:CASPERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HAZEL MARIE
Other - Middle Name:PATIAG
Other - Last Name:BALIITON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1425 N MCCARTHY RD APT 3
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8871
Mailing Address - Country:US
Mailing Address - Phone:706-618-7285
Mailing Address - Fax:
Practice Address - Street 1:325 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1325
Practice Address - Country:US
Practice Address - Phone:920-731-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11935-24225100000X
GAPT010262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist