Healthcare Provider Details

I. General information

NPI: 1639661119
Provider Name (Legal Business Name): ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 MARINETTE AVE
MARINETTE WI
54143-3801
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 715-735-5500
  • Fax: 715-735-5502
Mailing address:
  • Phone: 920-560-1083
  • Fax: 920-560-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

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