Provider Demographics
NPI:1770684854
Name:CHASE, KATHERINE A (PT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:CHASE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:BRUHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13508
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3508
Mailing Address - Country:US
Mailing Address - Phone:920-433-0111
Mailing Address - Fax:920-433-8765
Practice Address - Street 1:900 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3508
Practice Address - Country:US
Practice Address - Phone:920-433-0111
Practice Address - Fax:920-433-8765
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1544-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40265000Medicaid