Provider Demographics
NPI:1790997138
Name:MORRICAL, THERESE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
Last Name:MORRICAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:MARIE
Other - Last Name:WAMBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33107 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-6721
Mailing Address - Country:US
Mailing Address - Phone:262-534-3550
Mailing Address - Fax:
Practice Address - Street 1:2895 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-3743
Practice Address - Country:US
Practice Address - Phone:262-782-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2952-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist