Basic Information
| Provider Information | |||||||||
| NPI: | 1376986786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEISIUS | ||||||||
| FirstName: | TINA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5417 E BUSS RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535258805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083652620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 709 MEADOW PARK DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535259777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086762202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2013 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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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 | 225200000X | 762-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 762-19 | 01 | WI | PTA LICENSURE | OTHER |