Provider Demographics
NPI:1568911956
Name:SALM, CONSTANCE (PTA)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:SALM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JAMES ST
Mailing Address - Street 2:APT 208
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2855
Mailing Address - Country:US
Mailing Address - Phone:920-242-3737
Mailing Address - Fax:
Practice Address - Street 1:1902 MEAD AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6140
Practice Address - Country:US
Practice Address - Phone:920-458-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2529225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant