Healthcare Provider Details

I. General information

NPI: 1396302089
Provider Name (Legal Business Name): BENJAMIN THOMAS HEUSER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

IV. Provider business mailing address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-5559
  • Fax:
Mailing address:
  • Phone: 920-451-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14531-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: