Provider Demographics
NPI:1497056139
Name:WITTNEBEL, BETH (PT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:WITTNEBEL
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 1:5089 W COLLEGE AVE APT 45
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2959
Mailing Address - Country:US
Mailing Address - Phone:952-237-3291
Mailing Address - Fax:
Practice Address - Street 1:130 STRAWBERRY LN
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-2156
Practice Address - Country:US
Practice Address - Phone:715-424-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10561-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist