Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 104019 | WI |
NPI | 1013134105 |
---|---|
Provider Name | Betty Marie Spear |
First Address | Green Bay, WI 54301-2878 |
Second Address | Green Bay, WI 54301-2878 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 08/07/2007 |