Provider Demographics
NPI:1265200554
Name:HERSEY, DONALD BENJAMIN (LMT)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:BENJAMIN
Last Name:HERSEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4627
Mailing Address - Country:US
Mailing Address - Phone:847-287-5259
Mailing Address - Fax:
Practice Address - Street 1:3257 S 14TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4627
Practice Address - Country:US
Practice Address - Phone:847-287-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14917146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist