Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 4073 | WI |
NPI | 1043446172 |
---|---|
Provider Name | Charlene M Deters |
First Address | La Crosse, WI 54601-5429 |
Second Address | La Crosse, WI 54601-5429 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2009 |
Last Update Date | 03/06/2009 |