Provider Demographics
NPI:1609689116
Name:SEIDL, ERICK JON JR (BS, PTA)
Entity type:Individual
Prefix:MR
First Name:ERICK
Middle Name:JON
Last Name:SEIDL
Suffix:JR
Gender:M
Credentials:BS, PTA
Other - Prefix:
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Mailing Address - Street 1:235 LYNCH AVE
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:WI
Mailing Address - Zip Code:54208-9189
Mailing Address - Country:US
Mailing Address - Phone:920-784-1688
Mailing Address - Fax:
Practice Address - Street 1:200 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1708
Practice Address - Country:US
Practice Address - Phone:192-074-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4105-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant