Provider Demographics
NPI:1578506192
Name:TROTTIER, MARISA J
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:J
Last Name:TROTTIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:J
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:3701 80TH ST.
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-697-5290
Practice Address - Fax:262-697-1730
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10471-024225100000X
IL070015133225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40464500Medicaid
WI004185940Medicare ID - Type Unspecified