Basic Information
| Provider Information | |||||||||
| NPI: | 1023047099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARLEY | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 W GOOD HOPE RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532092042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143523100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530241700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623753700 | ||||||||
| FaxNumber: | 2623766020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 12/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4611 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00465813 | 01 | WI | RR MEDICARE | OTHER | 40218500 | 05 | WI | MEDICAID |