Healthcare Provider Details

I. General information

NPI: 1538858857
Provider Name (Legal Business Name): ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W CHAMPION DR
GRAND CHUTE WI
54913-5000
US

IV. Provider business mailing address

2105 E ENTERPRISE AVE STE 113
APPLETON WI
54913-7862
US

V. Phone/Fax

Practice location:
  • Phone: 920-560-1123
  • Fax: 920-202-3535
Mailing address:
  • Phone: 920-991-2561
  • Fax: 920-991-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: CAMILLA MEYER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 920-393-2819