Provider Demographics
NPI:1669613543
Name:GRESHAM, DAWN MARIE
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:EARHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12543 N SAINT ANNE CT
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2231
Mailing Address - Country:US
Mailing Address - Phone:262-238-1354
Mailing Address - Fax:
Practice Address - Street 1:2020 W WELLS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2720
Practice Address - Country:US
Practice Address - Phone:414-937-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35310242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics