Healthcare Provider Details

I. General information

NPI: 1073567004
Provider Name (Legal Business Name): SANDRA PACL P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 N PORT WASHINGTON RD
MEQUON WI
53092-3469
US

IV. Provider business mailing address

519 GREEN BAY RD
CEDARBURG WI
53012-9182
US

V. Phone/Fax

Practice location:
  • Phone: 262-387-8818
  • Fax:
Mailing address:
  • Phone: 262-375-4803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4545-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: