Provider Demographics
NPI:1184356883
Name:WALLGREN, ELISE M (PT)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:M
Last Name:WALLGREN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-246-6800
Mailing Address - Fax:
Practice Address - Street 1:9000 W SURA LN
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3477
Practice Address - Country:US
Practice Address - Phone:414-246-6800
Practice Address - Fax:414-246-6405
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100205207Medicaid