Healthcare Provider Details

I. General information

NPI: 1932184496
Provider Name (Legal Business Name): ROCHELLE A WURTH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 COMMANCHE AVE
GREEN BAY WI
54313-5753
US

IV. Provider business mailing address

1630 COMMANCHE AVE
GREEN BAY WI
54313-5753
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4750
  • Fax:
Mailing address:
  • Phone: 920-430-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9951
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: