Provider Demographics
NPI:1679054639
Name:KALLIO-CROTTEAU, SHELBY MARILYN MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:MARILYN MARIE
Last Name:KALLIO-CROTTEAU
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:SHELBY
Other - Middle Name:MARILYN MARIE
Other - Last Name:LOEPFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:GOODHUE HALL #200
Mailing Address - Street 2:800 WEST MAIN STREET
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190
Mailing Address - Country:US
Mailing Address - Phone:262-951-8774
Mailing Address - Fax:
Practice Address - Street 1:905 E GENEVA ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1922
Practice Address - Country:US
Practice Address - Phone:262-728-6319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2755-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant