Healthcare Provider Details

I. General information

NPI: 1699941005
Provider Name (Legal Business Name): SUSAN MARIE DELAET PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN MARIE LEE PTA

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 WEST LAYTON AVE
GREENFIELD WI
53220
US

IV. Provider business mailing address

5700 WEST LAYTON AVE
GREENFIELD WI
53220
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-7200
  • Fax: 414-282-7512
Mailing address:
  • Phone: 414-281-7200
  • Fax: 414-282-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number835019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: