Provider Demographics
NPI:1942569942
Name:GUCKENBERG, TONY (DPT)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:GUCKENBERG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 BRIARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-1206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 STEWART AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4148
Practice Address - Country:US
Practice Address - Phone:715-897-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11130-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist