Provider Demographics
NPI:1215101985
Name:MAYER, RICHARD ALAN (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALAN
Last Name:MAYER
Suffix:
Gender:M
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:S22W22660 BROADWAY
Mailing Address - Street 2:# 3A
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-8100
Mailing Address - Country:US
Mailing Address - Phone:262-549-1118
Mailing Address - Fax:262-549-1118
Practice Address - Street 1:S22W22660 BROADWAY
Practice Address - Street 2:# 3A
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-8100
Practice Address - Country:US
Practice Address - Phone:262-549-1118
Practice Address - Fax:262-549-1118
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1905-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40023900Medicaid