Provider Demographics
NPI:1679775688
Name:SCHROEDER, KELLY M (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SCHROEDER
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 1:4624 CEDAR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-8420
Mailing Address - Country:US
Mailing Address - Phone:414-507-9198
Mailing Address - Fax:
Practice Address - Street 1:4624 CEDAR LAKE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8420
Practice Address - Country:US
Practice Address - Phone:414-507-9198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36103400Medicaid