Provider Demographics
NPI:1487839759
Name:DE LA TORRE, LYNN (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:DE LA TORRE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:SHELMIDINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7300 WASHINGTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3821
Mailing Address - Country:US
Mailing Address - Phone:262-321-6000
Mailing Address - Fax:
Practice Address - Street 1:7300 WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3821
Practice Address - Country:US
Practice Address - Phone:262-321-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36136300Medicaid