=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831459924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE T SCHULZ PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2012
-----------------------------------------------------
Last Update Date | 05/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 MIDWAY RD
-----------------------------------------------------
City | MENASHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54952-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-329-2432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 CLEVELAND ST
-----------------------------------------------------
City | MENASHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54952-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-410-3129
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 915-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------