Healthcare Provider Details

I. General information

NPI: 1104514421
Provider Name (Legal Business Name): TIMOTHY PETRIE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3595
US

IV. Provider business mailing address

5136 N HOLLYWOOD AVE
WHITEFISH BAY WI
53217-5650
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-8656
  • Fax:
Mailing address:
  • Phone: 262-617-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number11022-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: