Provider Demographics
NPI:1437582624
Name:KROENCKE, MELISSA KAY (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:KAY
Last Name:KROENCKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:KAY
Other - Last Name:ZOERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:10724 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-4144
Practice Address - Country:US
Practice Address - Phone:414-545-0206
Practice Address - Fax:414-545-0281
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 28435225100000X
WI12962-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400209026Medicare PIN