Provider Demographics
NPI:1851036909
Name:THERAPEUTIC ADVANTAGE LLC
Entity Type:Organization
Organization Name:THERAPEUTIC ADVANTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-579-5168
Mailing Address - Street 1:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-1095
Mailing Address - Country:US
Mailing Address - Phone:920-579-5168
Mailing Address - Fax:920-479-2991
Practice Address - Street 1:W8645 HANNA LN
Practice Address - Street 2:
Practice Address - City:OAKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53065-9546
Practice Address - Country:US
Practice Address - Phone:920-979-6503
Practice Address - Fax:920-479-2991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790802684OtherNPI