Healthcare Provider Details

I. General information

NPI: 1346698883
Provider Name (Legal Business Name): GRETTA REPPERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETTA BAUER

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17280 W NORTH AVE STE 104
BROOKFIELD WI
53045-4366
US

IV. Provider business mailing address

2434 SPRINGDALE RD APT 205
WAUKESHA WI
53186-8715
US

V. Phone/Fax

Practice location:
  • Phone: 262-780-0707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13398-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: