Provider Demographics
NPI:1497490510
Name:BEDNAR, MICHELLE (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BEDNAR
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 BRISTOL CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1339
Mailing Address - Country:US
Mailing Address - Phone:414-350-5706
Mailing Address - Fax:
Practice Address - Street 1:2722 BRISTOL CT
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1339
Practice Address - Country:US
Practice Address - Phone:414-350-5706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12936-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist