Provider Demographics
NPI:1548783228
Name:ABENDROTH, KELSEY MAE (PT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MAE
Last Name:ABENDROTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:MAE
Other - Last Name:UHLENBRAUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2000
Practice Address - Fax:920-531-2098
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1548783228Medicaid