Provider Demographics
NPI:1477189272
Name:WENTLANDT, TAMMY R (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:R
Last Name:WENTLANDT
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13825 W BURLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3058
Mailing Address - Country:US
Mailing Address - Phone:262-754-3450
Mailing Address - Fax:
Practice Address - Street 1:13825 W BURLEIGH RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3058
Practice Address - Country:US
Practice Address - Phone:262-754-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12578-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist