Healthcare Provider Details

I. General information

NPI: 1881859122
Provider Name (Legal Business Name): ANN MATTSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 22ND AVE
MONROE WI
53566-1569
US

IV. Provider business mailing address

9935 W SABIN CHURCH RD
PEARL CITY IL
61062-9035
US

V. Phone/Fax

Practice location:
  • Phone: 608-324-2770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160004898
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: