Provider Demographics
NPI:1871163014
Name:TETZKE, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:TETZKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W160N10476 BROOK HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-5708
Mailing Address - Country:US
Mailing Address - Phone:262-527-8380
Mailing Address - Fax:
Practice Address - Street 1:140 E RAWSON AVE STE 317
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1525
Practice Address - Country:US
Practice Address - Phone:262-287-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15434-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist