Provider Demographics
NPI:1881982908
Name:WEST, TRISHA R (DPT, LAT)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:R
Last Name:WEST
Suffix:
Gender:F
Credentials:DPT, LAT
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:R
Other - Last Name:GUDEX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, LAT
Mailing Address - Street 1:620 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1702
Mailing Address - Country:US
Mailing Address - Phone:920-324-6544
Mailing Address - Fax:
Practice Address - Street 1:620 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-324-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11783-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist