Provider Demographics
NPI:1417188673
Name:BLASER, KATHRYN A (DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:BLASER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:A
Other - Last Name:BURKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:723 S WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:WI
Practice Address - Zip Code:54162-9303
Practice Address - Country:US
Practice Address - Phone:920-822-1100
Practice Address - Fax:920-822-5731
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11210-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851477913OtherCMH NPI
WI11014110Medicaid
WI11210-024OtherWI LICENSE
WI390848401050OtherANTHEM
WI030280053Medicare Oscar/Certification
WI1851477913OtherCMH NPI
WI390848401050OtherANTHEM
WI11014110Medicaid