Healthcare Provider Details

I. General information

NPI: 1639718174
Provider Name (Legal Business Name): GWENDOLYNN SUE DOYLE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 JEFFERSON STREET
BARABOO WI
53913
US

IV. Provider business mailing address

1414 JEFFERSON STREET
BARABOO WI
53913
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-8538
  • Fax: 608-355-3333
Mailing address:
  • Phone: 608-356-8538
  • Fax: 608-355-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3008-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: