Provider Demographics
NPI:1215095476
Name:DETTWILER, SARAH ANN (LAT, PTA)
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:ANN
Last Name:DETTWILER
Suffix:
Gender:F
Credentials:LAT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WASHINGTON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3043
Mailing Address - Country:US
Mailing Address - Phone:920-553-8993
Mailing Address - Fax:920-553-8990
Practice Address - Street 1:1400 WASHINGTON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3043
Practice Address - Country:US
Practice Address - Phone:920-553-8993
Practice Address - Fax:920-553-8990
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1275-019225200000X
WI605-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer