Basic Information
| Provider Information | |||||||||
| NPI: | 1154911600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | NOELLE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22826 S ANNA DR | ||||||||
| Address2: | |||||||||
| City: | CHANNAHON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604103237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159319751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15465 W HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531515273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627864422 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2021 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 15324-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.