Basic Information
| Provider Information | |||||||||
| NPI: | 1164778718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAUTH | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WESTERLUND | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | D. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3048 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626570222 | ||||||||
| FaxNumber: | 2626577190 | ||||||||
| Practice Location | |||||||||
| Address1: | 237 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TWIN LAKES | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531819681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628774884 | ||||||||
| FaxNumber: | 2628774629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2012 | ||||||||
| LastUpdateDate: | 01/25/2013 | ||||||||
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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 | 11995-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 859400079 | 01 | WI | MEDICARE | OTHER | P01113279 | 01 | WI | RAILROAD MEDICARE | OTHER |