Provider Demographics
NPI:1760729784
Name:WELL & READY KIDS LLC
Entity Type:Organization
Organization Name:WELL & READY KIDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRENCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-376-9335
Mailing Address - Street 1:510 E WISCONSIN AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-4865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 E WISCONSIN AVE STE 4
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4865
Practice Address - Country:US
Practice Address - Phone:920-376-9335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4976-26225XM0800X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992082259Medicaid