Provider Demographics
NPI:1578530739
Name:WOLLET, JAMES G (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:WOLLET
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 VALLEY SPRING RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-1239
Mailing Address - Country:US
Mailing Address - Phone:608-798-3069
Mailing Address - Fax:
Practice Address - Street 1:3433 VALLEY SPRING RD
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1239
Practice Address - Country:US
Practice Address - Phone:608-798-3069
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2637-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40077700Medicaid