Provider Demographics
NPI:1588610562
Name:FRESH START PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FRESH START PHYSICAL THERAPY LLC
Other - Org Name:HEALTH IN BALANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN LAANEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:262-236-0176
Mailing Address - Street 1:7602 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-3215
Mailing Address - Country:US
Mailing Address - Phone:262-236-0176
Mailing Address - Fax:262-236-0178
Practice Address - Street 1:7602 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-3215
Practice Address - Country:US
Practice Address - Phone:262-236-0176
Practice Address - Fax:262-236-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40426100Medicaid