Provider Demographics
NPI:1679790307
Name:ANDERSON, DONNA J (PT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-6445
Mailing Address - Country:US
Mailing Address - Phone:715-421-8855
Mailing Address - Fax:715-421-2266
Practice Address - Street 1:2611 12TH ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6445
Practice Address - Country:US
Practice Address - Phone:715-421-8855
Practice Address - Fax:715-421-2266
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2561-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40173900Medicaid