Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics |
NPI | 1083879647 |
---|---|
Provider Name | Mrs. Marlene Pettit Bott |
First Address | Waukesha, WI 53189 |
Second Address | Waukesha, WI 53188-3175 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2008 |
Last Update Date | 23/07/2008 |