Provider Demographics
NPI:1255401675
Name:WEGEHAUPT, JUDITH LEIGH (PT)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LEIGH
Last Name:WEGEHAUPT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10579 FIELDCREST RD
Mailing Address - Street 2:
Mailing Address - City:SISTER BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54234-9188
Mailing Address - Country:US
Mailing Address - Phone:414-232-1018
Mailing Address - Fax:
Practice Address - Street 1:1673 DOUSMAN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3209
Practice Address - Country:US
Practice Address - Phone:920-593-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1836-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255401675Medicaid
WI521358Medicare Oscar/Certification