Provider Demographics
NPI:1417211798
Name:WALDSCHMIDT, AUDREY MARY (PTA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MARY
Last Name:WALDSCHMIDT
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 1:3223 WALL ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-9601
Mailing Address - Country:US
Mailing Address - Phone:920-863-8416
Mailing Address - Fax:
Practice Address - Street 1:1229 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3037
Practice Address - Country:US
Practice Address - Phone:920-437-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI242-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant