Healthcare Provider Details

I. General information

NPI: 1265585913
Provider Name (Legal Business Name): RACHEL GRACE TYLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 GARFIELD AVE
EVANSVILLE WI
53536-1014
US

IV. Provider business mailing address

1707 BARHAM AVE
JANESVILLE WI
53548-1510
US

V. Phone/Fax

Practice location:
  • Phone: 608-882-6557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1243-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: