Provider Demographics
NPI:1265720122
Name:BAETHKE, ROXANNE MARIE (PTA)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:MARIE
Last Name:BAETHKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MONTGOMERY ST
Mailing Address - Street 2:TEAM REHAB LC
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101
Mailing Address - Country:US
Mailing Address - Phone:563-382-4770
Mailing Address - Fax:563-382-4785
Practice Address - Street 1:516 MONTGOMERY ST
Practice Address - Street 2:TEAM REHAB LC
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101
Practice Address - Country:US
Practice Address - Phone:563-382-4770
Practice Address - Fax:563-382-4785
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI10015Medicare UPIN