Basic Information
| Provider Information | |||||||||
| NPI: | 1790949022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | READY | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDER LOOP | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | N4231 HWY 22 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155263158 | ||||||||
| FaxNumber: | 7155266225 | ||||||||
| Practice Location | |||||||||
| Address1: | N 4231 HWY 22 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541664166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155263158 | ||||||||
| FaxNumber: | 7155266225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 199-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40237400 | 05 | WI | MEDICAID |