Healthcare Provider Details

I. General information

NPI: 1770123101
Provider Name (Legal Business Name): BAILEY L LANSER DPT, AT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 KEPLER DR
GREEN BAY WI
54311-8321
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5630
  • Fax:
Mailing address:
  • Phone: 920-288-5536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number14610-24
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14610
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: