Provider Demographics
NPI:1558329821
Name:VANAACKEN, TERESA M (PT DPT OCS CSCS)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:VANAACKEN
Suffix:
Gender:F
Credentials:PT DPT OCS CSCS
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:N
Other - Last Name:ROMITTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:300 S KOELLER STREET
Practice Address - Street 2:SUITE B
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902
Practice Address - Country:US
Practice Address - Phone:920-231-5195
Practice Address - Fax:920-231-5196
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6434024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40361100Medicaid
WIP00431919Medicare PIN
WIP00431919Medicare UPIN
WI40361100Medicaid
WI000186165Medicare PIN