Healthcare Provider Details

I. General information

NPI: 1386977155
Provider Name (Legal Business Name): MEGAN ROSE GASPERICH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S. 9TH ST.
DEPERE WI
54115
US

IV. Provider business mailing address

1450 SILVERSTONE TRAIL APT. 9
DEPERE WI
54115
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-4146
  • Fax:
Mailing address:
  • Phone: 920-819-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1551-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: