Provider Demographics
NPI:1700015518
Name:PRESTBY, LAURIE G (PT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:G
Last Name:PRESTBY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1700 W PARADISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:262-306-2964
Practice Address - Street 1:1190 E PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5444
Practice Address - Country:US
Practice Address - Phone:262-306-6319
Practice Address - Fax:262-306-2964
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WI2142225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700015518Medicaid
WI2142-024OtherSTATE LICENSE