Provider Demographics
NPI:1790767325
Name:HERSCHLEB, RAYMOND GEORGE (MPT)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:GEORGE
Last Name:HERSCHLEB
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 S LAYTON BLVD
Mailing Address - Street 2:SUITE 224
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-1924
Mailing Address - Country:US
Mailing Address - Phone:414-902-2430
Mailing Address - Fax:414-944-0002
Practice Address - Street 1:1555 S LAYTON BLVD
Practice Address - Street 2:SUITE 224
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1924
Practice Address - Country:US
Practice Address - Phone:414-902-2430
Practice Address - Fax:414-944-0002
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40306800Medicaid
WI40306800Medicaid
WI000180074Medicare ID - Type UnspecifiedLIFESPEED