Provider Demographics
NPI:1770824856
Name:VAVRA, DENISE (PT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:VAVRA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S67W29571 COUNTY ROAD I
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9717
Mailing Address - Country:US
Mailing Address - Phone:262-968-2303
Mailing Address - Fax:
Practice Address - Street 1:800 GENEVA PKWY N
Practice Address - Street 2:SUITE 3
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-5701
Practice Address - Country:US
Practice Address - Phone:262-248-9902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4526-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist