Provider Demographics
NPI:1942463021
Name:THEISS, KATHERINE M (PTA)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:M
Last Name:THEISS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 E WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3101
Mailing Address - Country:US
Mailing Address - Phone:715-842-2028
Mailing Address - Fax:
Practice Address - Street 1:1010 E WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3101
Practice Address - Country:US
Practice Address - Phone:715-842-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1127-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40463600Medicaid