Healthcare Provider Details

I. General information

NPI: 1932152311
Provider Name (Legal Business Name): MOLLY BURKE DUDEK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E. NEWPORT AVE. COLUMBIA-ST. MARY'S HOSPITAL
MILWAUKEE WI
53211
US

IV. Provider business mailing address

5660 N LYDELL AVE
MILWAUKEE WI
53217-4525
US

V. Phone/Fax

Practice location:
  • Phone: 414-961-4160
  • Fax:
Mailing address:
  • Phone: 414-332-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1066-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: