Healthcare Provider Details

I. General information

NPI: 1689375834
Provider Name (Legal Business Name): CLAIRE INGISH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

142 LAUREL DR N
WEST BEND WI
53095-5005
US

V. Phone/Fax

Practice location:
  • Phone: 262-483-9322
  • Fax:
Mailing address:
  • Phone: 262-483-9322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3326-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: