Basic Information
| Provider Information | |||||||||
| NPI: | 1881090579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROVELLI | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 LONE OAK LN | ||||||||
| Address2: | HARTFORD HEALTH CENTER | ||||||||
| City: | HARTFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626701800 | ||||||||
| FaxNumber: | 2628361601 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LONE OAK LN | ||||||||
| Address2: | HARTFORD HEALTH CENTER | ||||||||
| City: | HARTFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626701800 | ||||||||
| FaxNumber: | 2628361601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2014 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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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 | 12864 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1881090579 | 05 | WI | MEDICAID |