Provider Demographics
NPI:1639112576
Name:PERRY, CONNIE JEAN (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JEAN
Last Name:PERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 S 13TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1832
Mailing Address - Country:US
Mailing Address - Phone:414-764-2871
Mailing Address - Fax:414-764-6475
Practice Address - Street 1:7300 S 13TH ST STE 204
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1832
Practice Address - Country:US
Practice Address - Phone:414-764-2871
Practice Address - Fax:414-764-6475
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9652024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000201659Medicare PIN