Provider Demographics
NPI:1558518944
Name:VELDT, EVAN (PTA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:VELDT
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 1:506 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:BLACK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54106-9720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 N CLARK ST
Practice Address - Street 2:
Practice Address - City:BLACK CREEK
Practice Address - State:WI
Practice Address - Zip Code:54106-9720
Practice Address - Country:US
Practice Address - Phone:920-265-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1270-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant