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General NPI Number Information
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NPI Number | 1104514421
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Entity Type | Individual
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Provider Name | TIMOTHY PETRIE DPT
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Gender | Male
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Dates
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Enumeration Date | 04/25/2023
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Last Update Date | 04/25/2023
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Provider Practice Location Address
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Address Line | 8700 WATERTOWN PLANK RD
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City | MILWAUKEE
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State | WI
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Zip | 53226-3595
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Country | US
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Telephone | 414-805-8656
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Fax |
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Provider Business Mailing Address
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Address Line | 5136 N HOLLYWOOD AVE
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City | WHITEFISH BAY
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State | WI
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Zip | 53217-5650
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Country | US
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Telephone | 262-617-5953
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 11022-24
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License Number State | WI
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