Healthcare Provider Details

I. General information

NPI: 1033543798
Provider Name (Legal Business Name): EQUIMOTION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 GAGE LN
SOLDIERS GROVE WI
54655-8564
US

IV. Provider business mailing address

10750 GAGE LN
SOLDIERS GROVE WI
54655-8564
US

V. Phone/Fax

Practice location:
  • Phone: 608-632-4459
  • Fax: 608-638-7429
Mailing address:
  • Phone: 608-632-4459
  • Fax: 608-638-7429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number15790-131
License Number StateWI

VIII. Authorized Official

Name: KATHERINE E BURKE
Title or Position: OWNER
Credential: SAC
Phone: 608-632-4459