Healthcare Provider Details

I. General information

NPI: 1083681407
Provider Name (Legal Business Name): PAUL E NIEMUTH PT,DSC,OCS,SCS,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 ASH ST SUITE 5
SPOONER WI
54801-1487
US

IV. Provider business mailing address

600 52ND ST STE 240
KENOSHA WI
53140-3423
US

V. Phone/Fax

Practice location:
  • Phone: 715-635-2518
  • Fax: 866-245-8064
Mailing address:
  • Phone: 262-925-5000
  • Fax: 262-925-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1739
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1811-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: