Provider Demographics
NPI:1639767718
Name:DEMCAK, DESIREE LYNN (PT)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:LYNN
Last Name:DEMCAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:LYNN
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1821 S STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2257
Mailing Address - Country:US
Mailing Address - Phone:608-260-6000
Mailing Address - Fax:608-260-6906
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6906
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12097225100000X
WI16871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639767718Medicaid