Healthcare Provider Details

I. General information

NPI: 1316014731
Provider Name (Legal Business Name): BETH ANN POUK MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2294 PIONEER DR
BELOIT WI
53511-2547
US

IV. Provider business mailing address

2294 PIONEER DR
BELOIT WI
53511-2547
US

V. Phone/Fax

Practice location:
  • Phone: 608-365-2308
  • Fax:
Mailing address:
  • Phone: 608-365-2308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number331-039
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: