Basic Information
| Provider Information | |||||||||
| NPI: | 1598249013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | W4978 PORTER RD | ||||||||
| Address2: | |||||||||
| City: | BONDUEL | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541078805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1625 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTONVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549298407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158233135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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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 | 2373-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.