Provider Demographics
NPI:1013120872
Name:CHURCHILL, CHRISTINE MARIE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 S MADELINE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3950
Mailing Address - Country:US
Mailing Address - Phone:414-423-9891
Mailing Address - Fax:
Practice Address - Street 1:2730 W RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-4814
Practice Address - Country:US
Practice Address - Phone:414-282-2600
Practice Address - Fax:414-282-2051
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI557-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36126900Medicaid