Provider Demographics
NPI:1407179872
Name:WELLS-MANGOLD, ROBYN ALICE (PT)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:ALICE
Last Name:WELLS-MANGOLD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9368
Mailing Address - Country:US
Mailing Address - Phone:715-386-1155
Mailing Address - Fax:715-386-1105
Practice Address - Street 1:1830 HANLEY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9368
Practice Address - Country:US
Practice Address - Phone:715-386-1155
Practice Address - Fax:715-386-1105
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13604225100000X, 225100000X
KY005733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist