Healthcare Provider Details

I. General information

NPI: 1487784179
Provider Name (Legal Business Name): SHALLA MARLENE ACKER P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 ASH ST
SPOONER WI
54801-1201
US

IV. Provider business mailing address

819 ASH ST
SPOONER WI
54801-1201
US

V. Phone/Fax

Practice location:
  • Phone: 715-635-2111
  • Fax: 715-635-8674
Mailing address:
  • Phone: 715-635-2111
  • Fax: 715-635-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number37005
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: