Provider Demographics
NPI:1770123101
Name:LANSER, BAILEY L (DPT, AT)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:L
Last Name:LANSER
Suffix:
Gender:F
Credentials:DPT, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:920-288-5536
Mailing Address - Fax:
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14610-242081S0010X
WI14610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine