Provider Demographics
NPI:1518648906
Name:BOEHLKE, JOSHUA SCOTT (PTA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:SCOTT
Last Name:BOEHLKE
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 1:3015 MAPLE VALLEY DR APT 302
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-3188
Mailing Address - Country:US
Mailing Address - Phone:920-540-0050
Mailing Address - Fax:
Practice Address - Street 1:407 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1872
Practice Address - Country:US
Practice Address - Phone:608-470-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant