=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750548806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEANA VAN BAALEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2008
-----------------------------------------------------
Last Update Date | 01/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2520 FOX RIVER PKWY
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53189-7747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-446-4842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2520 FOX RIVER PKWY
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53189-7747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5449-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------