Provider Demographics
NPI:1689019903
Name:BAVIN, EMILY JO (PTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JO
Last Name:BAVIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:JO
Other - Last Name:PERRAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:750 EAST LOUSIANA ST
Mailing Address - Street 2:
Mailing Address - City:ST. CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54204
Mailing Address - Country:US
Mailing Address - Phone:715-483-2713
Mailing Address - Fax:715-483-2725
Practice Address - Street 1:750 EAST LOUSIANA ST
Practice Address - Street 2:
Practice Address - City:ST. CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54204
Practice Address - Country:US
Practice Address - Phone:715-483-2713
Practice Address - Fax:715-483-2725
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1989-19225200000X
MNA1421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant