Basic Information
Provider Information | |||||||||
NPI: | 1841411303 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STAEHLER | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAMPE | ||||||||
OtherFirstName: | CHERYL | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 240 MARINA CT UNIT 32 | ||||||||
Address2: |   | ||||||||
City: | WATERFORD | ||||||||
State: | WI | ||||||||
PostalCode: | 531854477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622106288 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8633 32ND AVE | ||||||||
Address2: |   | ||||||||
City: | KENOSHA | ||||||||
State: | WI | ||||||||
PostalCode: | 531425187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626948300 | ||||||||
FaxNumber: | 2626949125 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 334-019 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 40377800 | 05 | WI |   | MEDICAID |