Provider Demographics
NPI:1154765303
Name:MAGNUS, ELISABETH (PT)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:MAGNUS
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 1:13105 WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2213
Mailing Address - Country:US
Mailing Address - Phone:262-787-1375
Mailing Address - Fax:
Practice Address - Street 1:13105 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2213
Practice Address - Country:US
Practice Address - Phone:262-787-1375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4387-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist