Basic Information
| Provider Information | |||||||||
| NPI: | 1285948315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENZEL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S., CES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 W BELTLINE HWY | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176102 | ||||||||
| FaxNumber: | 6084175770 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 W BELTLINE HWY | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176102 | ||||||||
| FaxNumber: | 6084175770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2010 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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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 | 224Y00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Clinical Exercise Physiologist |
ID Information
| ID | Type | State | Issuer | Description | 11001700 | 05 | WI | MEDICAID |