Provider Demographics
NPI:1932113420
Name:MARGONI, BRENDA J (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:MARGONI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:J
Other - Last Name:RADTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2500 W LAYTON AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5421
Mailing Address - Country:US
Mailing Address - Phone:414-389-3023
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAYTON AVE STE 160
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5421
Practice Address - Country:US
Practice Address - Phone:414-389-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36117800Medicaid