Healthcare Provider Details

I. General information

NPI: 1043240039
Provider Name (Legal Business Name): JANET SUSAN INGOLD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD
MEQUON WI
53097-2416
US

IV. Provider business mailing address

1791 COUNTY ROAD K
HARTFORD WI
53027-9023
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7444
  • Fax:
Mailing address:
  • Phone: 262-670-0669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number572-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: