Provider Demographics
NPI:1811276660
Name:BROWN, PRESTON (PT)
Entity type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 LEGEND HILL LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-8088
Mailing Address - Country:US
Mailing Address - Phone:262-880-4664
Mailing Address - Fax:262-436-1470
Practice Address - Street 1:1604 LEGEND HILL LN
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-8088
Practice Address - Country:US
Practice Address - Phone:262-880-4664
Practice Address - Fax:262-436-1470
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10950-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811276660Medicaid
WI1811276660Medicaid