Provider Demographics
NPI:1437171519
Name:FANTAZZI, MAUREEN J (PT)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:J
Last Name:FANTAZZI
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:PO BOX 0811433
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53408-4133
Mailing Address - Country:US
Mailing Address - Phone:262-321-0240
Mailing Address - Fax:262-321-0242
Practice Address - Street 1:5663 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-4107
Practice Address - Country:US
Practice Address - Phone:414-282-7810
Practice Address - Fax:414-282-9120
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1533-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40019500Medicaid