Provider Demographics
NPI:1831223213
Name:SCHULTZ, SUSAN MR (PTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MR
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:WI
Mailing Address - Zip Code:53119-2249
Mailing Address - Country:US
Mailing Address - Phone:262-594-5695
Mailing Address - Fax:
Practice Address - Street 1:13105 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2213
Practice Address - Country:US
Practice Address - Phone:262-782-1450
Practice Address - Fax:262-782-2349
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1073019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant