Provider Demographics
NPI:1265566038
Name:MASSART, TIMOTHEA A (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHEA
Middle Name:A
Last Name:MASSART
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2073
Mailing Address - Country:US
Mailing Address - Phone:920-884-6100
Mailing Address - Fax:920-884-6311
Practice Address - Street 1:1239 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2047
Practice Address - Country:US
Practice Address - Phone:920-884-6100
Practice Address - Fax:920-884-6311
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3848-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38941700Medicaid
WI000035483Medicare ID - Type Unspecified
WIU94191Medicare UPIN