Provider Demographics
NPI:1063082626
Name:EXTEND PHYSICAL THERAPY AND WELLNESS
Entity type:Organization
Organization Name:EXTEND PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NAEGELI
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:262-902-7881
Mailing Address - Street 1:1648 KUIPER LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4310
Mailing Address - Country:US
Mailing Address - Phone:262-902-7881
Mailing Address - Fax:
Practice Address - Street 1:1648 KUIPER LN
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4310
Practice Address - Country:US
Practice Address - Phone:262-902-7881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty