Provider Demographics
NPI:1518118793
Name:PITTSLEY, RICHARD (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PITTSLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8633 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-5187
Mailing Address - Country:US
Mailing Address - Phone:262-694-8800
Mailing Address - Fax:
Practice Address - Street 1:8633 32ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-5187
Practice Address - Country:US
Practice Address - Phone:262-694-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1446-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36177900Medicaid