Provider Demographics
NPI:1477511509
Name:TEBERG, TED N (PT)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:N
Last Name:TEBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 52ND ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3423
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:204 SOUTH PINE STREET
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105
Practice Address - Country:US
Practice Address - Phone:262-767-9579
Practice Address - Fax:262-767-9610
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4607024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40391100Medicaid
000183060Medicare ID - Type Unspecified