Provider Demographics
NPI:1154911600
Name:SIMON, LAURA NOELLE (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:NOELLE
Last Name:SIMON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22826 S ANNA DR
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-3237
Mailing Address - Country:US
Mailing Address - Phone:815-931-9751
Mailing Address - Fax:
Practice Address - Street 1:15465 W HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5273
Practice Address - Country:US
Practice Address - Phone:262-786-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15324-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist