Healthcare Provider Details

I. General information

NPI: 1851958508
Provider Name (Legal Business Name): KELLY WOLF PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19475 SILVER CREEK RD
GALESVILLE WI
54630-6400
US

IV. Provider business mailing address

N1418 TIMBER VALLEY RD
LA CROSSE WI
54601-2172
US

V. Phone/Fax

Practice location:
  • Phone: 608-582-2211
  • Fax:
Mailing address:
  • Phone: 608-787-6386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number817-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: