Provider Demographics
NPI:1558430082
Name:WENGER-NUSSBAUM, CARLA (PT)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:WENGER-NUSSBAUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:WENGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:328 N MICHIGAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1244
Mailing Address - Country:US
Mailing Address - Phone:574-647-1842
Mailing Address - Fax:574-647-1825
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:SUITE 6650
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1156
Practice Address - Country:US
Practice Address - Phone:574-647-5007
Practice Address - Fax:574-647-6775
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002607A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics