Healthcare Provider Details

I. General information

NPI: 1912674631
Provider Name (Legal Business Name): BETHANY PETSCH PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY NELSON PT, DPT

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13203 GLOBE DR STE 111
MOUNT PLEASANT WI
53177-1616
US

IV. Provider business mailing address

1550 N WARREN AVE APT 313
MILWAUKEE WI
53202-7800
US

V. Phone/Fax

Practice location:
  • Phone: 262-287-0090
  • Fax:
Mailing address:
  • Phone: 262-352-9309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15582-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: