Basic Information
| Provider Information | |||||||||
| NPI: | 1699704296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUMEISTER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTRL | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNNER | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OTRL | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3601 30TH AVE | ||||||||
| Address2: | STE 103 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626570222 | ||||||||
| FaxNumber: | 2626577190 | ||||||||
| Practice Location | |||||||||
| Address1: | 25250 75TH ST | ||||||||
| Address2: | |||||||||
| City: | PADDOCK LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628434200 | ||||||||
| FaxNumber: | 2628434578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 12/04/2017 | ||||||||
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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 | 056006611 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 3629026 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 224Z00000X | 3629 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40836800 | 05 | WI | MEDICAID | P00073608 | 01 | WI | RAILROAD MEDICARE NUMBER | OTHER | 0604410001 | 01 | WI | DMERC | OTHER |