Provider Demographics
NPI:1871872358
Name:NELSON, THERESA SUE (PTA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:SUE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11779 N LOFQUIST RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6434
Mailing Address - Country:US
Mailing Address - Phone:715-699-9837
Mailing Address - Fax:
Practice Address - Street 1:706 BRATLEY DR
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-1143
Practice Address - Country:US
Practice Address - Phone:715-373-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1733-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant