Provider Demographics
NPI:1881852127
Name:GUNDLACH, JUDY E (PT)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:E
Last Name:GUNDLACH
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 1:2025 W OKLAHOMA AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4455
Mailing Address - Country:US
Mailing Address - Phone:414-647-7678
Mailing Address - Fax:
Practice Address - Street 1:2025 W OKLAHOMA AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4455
Practice Address - Country:US
Practice Address - Phone:414-647-7678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2209OtherPHYSICAL THERAPY LICENSE