Healthcare Provider Details

I. General information

NPI: 1013054832
Provider Name (Legal Business Name): GWEN PEARSON HOP MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 HOSPITAL RD
NEW RICHMOND WI
54017-1449
US

IV. Provider business mailing address

211 N STARR AVE
NEW RICHMOND WI
54017-1231
US

V. Phone/Fax

Practice location:
  • Phone: 715-243-7255
  • Fax:
Mailing address:
  • Phone: 715-246-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5355-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: