Provider Demographics
NPI:1639234297
Name:BALISTRERI-RODEN, SUZANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:
Last Name:BALISTRERI-RODEN
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 1:1787 KNOB RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-8603
Mailing Address - Country:US
Mailing Address - Phone:262-942-0163
Mailing Address - Fax:262-948-3920
Practice Address - Street 1:902 S WELLS ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2422
Practice Address - Country:US
Practice Address - Phone:262-249-1915
Practice Address - Fax:262-249-1397
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2698-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist