Provider Demographics
NPI:1740594795
Name:NELSON, KATHRYN (DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:LAVENTURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7854 BLACK RIVER RD
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-9501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6630 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3036
Practice Address - Country:US
Practice Address - Phone:608-263-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11579-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist