Provider Demographics
NPI:1740494699
Name:DAVIS, DEBRA KAY (LPTA)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:KAY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7115 W VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WIND LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53185-1929
Mailing Address - Country:US
Mailing Address - Phone:414-881-1549
Mailing Address - Fax:
Practice Address - Street 1:2727 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-2259
Practice Address - Country:US
Practice Address - Phone:414-383-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1023-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36121000Medicaid