Provider Demographics
NPI:1972612729
Name:WILCOX, MARLENE (PTA)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 WESTHILL DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3402 HOWLAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5633
Practice Address - Country:US
Practice Address - Phone:715-355-5701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40454000Medicaid