Provider Demographics
NPI:1245279967
Name:WILKENS, COLLEEN ANN (PT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:WILKENS
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10590 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5537
Mailing Address - Country:US
Mailing Address - Phone:262-375-1075
Mailing Address - Fax:262-375-4975
Practice Address - Street 1:1510 UNDERWOOD AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2619
Practice Address - Country:US
Practice Address - Phone:262-375-1075
Practice Address - Fax:262-375-4975
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6273-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40318200Medicaid
WI0038Medicare ID - Type Unspecified