Provider Demographics
NPI:1407849730
Name:PLEVA, LARRY JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JOHN
Last Name:PLEVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 COLLEGE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1150
Mailing Address - Country:US
Mailing Address - Phone:414-571-9146
Mailing Address - Fax:414-571-9147
Practice Address - Street 1:1333 COLLEGE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-1150
Practice Address - Country:US
Practice Address - Phone:414-571-9146
Practice Address - Fax:414-571-9147
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4037500Medicaid