Healthcare Provider Details

I. General information

NPI: 1558033720
Provider Name (Legal Business Name): MADELEINE BROOKE HEPPERLEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S MAIN ST STE 302
VIROQUA WI
54665-2100
US

IV. Provider business mailing address

2426 HENGEL CT APT 104
LA CROSSE WI
54601-7547
US

V. Phone/Fax

Practice location:
  • Phone: 608-637-4385
  • Fax:
Mailing address:
  • Phone: 815-382-2812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15629-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: