Provider Demographics
NPI:1841409497
Name:MUELLENBACH, ELIZABETH JANE (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JANE
Last Name:MUELLENBACH
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 1:3972 ELAINES WAY
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9631
Mailing Address - Country:US
Mailing Address - Phone:262-644-4512
Mailing Address - Fax:
Practice Address - Street 1:1048 E COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9326
Practice Address - Country:US
Practice Address - Phone:262-644-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40284500Medicaid