Provider Demographics
NPI:1134522170
Name:MORTAG, ELIZABETH MARIE (DPT)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:MORTAG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 N 142ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-1142
Mailing Address - Country:US
Mailing Address - Phone:309-360-4162
Mailing Address - Fax:
Practice Address - Street 1:W225N16711 CEDAR PARK CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037-9222
Practice Address - Country:US
Practice Address - Phone:262-677-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-05
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12680-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist