Healthcare Provider Details

I. General information

NPI: 1336418854
Provider Name (Legal Business Name): SUZANNE PATRICIA INGEBRIGTSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE PATRICIA LARUE PTA

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 195TH ST
DRESSER WI
54009-4455
US

IV. Provider business mailing address

997 195TH ST P.O. BOX 187
DRESSER WI
54009-4455
US

V. Phone/Fax

Practice location:
  • Phone: 715-755-2118
  • Fax:
Mailing address:
  • Phone: 715-755-2118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number582-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: