Provider Demographics
NPI:1952670481
Name:DALCANTON, MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DALCANTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5732 80TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4185
Mailing Address - Country:US
Mailing Address - Phone:262-697-8572
Mailing Address - Fax:
Practice Address - Street 1:5732 80TH ST APT 2
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4185
Practice Address - Country:US
Practice Address - Phone:262-697-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1548-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant