Provider Demographics
NPI:1780761411
Name:WAHLSTROM, NEIL A (PT, MBA)
Entity type:Individual
Prefix:MR
First Name:NEIL
Middle Name:A
Last Name:WAHLSTROM
Suffix:
Gender:M
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-9083
Mailing Address - Country:US
Mailing Address - Phone:715-477-1523
Mailing Address - Fax:715-477-1524
Practice Address - Street 1:528 W PINE ST
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-9083
Practice Address - Country:US
Practice Address - Phone:715-477-1523
Practice Address - Fax:715-477-1524
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5819-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40302900Medicaid