Provider Demographics
NPI:1639543150
Name:LONDO, TAYLOR ALEXIS (DPT)
Entity Type:Individual
Prefix:MISS
First Name:TAYLOR
Middle Name:ALEXIS
Last Name:LONDO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:A
Other - Last Name:GRANQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:218 S HWY 141
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1677
Practice Address - Country:US
Practice Address - Phone:715-854-7761
Practice Address - Fax:715-854-7785
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019200225100000X
WI14780-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist