Healthcare Provider Details

I. General information

NPI: 1407953888
Provider Name (Legal Business Name): EMILY ANDERSON LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GATEWAY CT
WEST BEND WI
53095
US

IV. Provider business mailing address

1100 GATEWAY CT
WEST BEND WI
53095-8539
US

V. Phone/Fax

Practice location:
  • Phone: 262-306-6100
  • Fax: 262-306-6105
Mailing address:
  • Phone: 262-573-5333
  • Fax: 262-306-3105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number689-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: