Healthcare Provider Details

I. General information

NPI: 1588610562
Provider Name (Legal Business Name): FRESH START PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10412 N BAEHR RD
MEQUON WI
53092-4472
US

IV. Provider business mailing address

10412 N BAEHR RD
MEQUON WI
53092-4472
US

V. Phone/Fax

Practice location:
  • Phone: 262-236-0176
  • Fax: 262-236-0178
Mailing address:
  • Phone: 262-236-0176
  • Fax: 262-236-0178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHARISE WORTHINGTON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 262-236-0176