Provider Demographics
NPI:1285801175
Name:HUMPAL, MARY ELLEN (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:HUMPAL
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 1:4010 S 104TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2012
Mailing Address - Country:US
Mailing Address - Phone:414-545-4423
Mailing Address - Fax:
Practice Address - Street 1:4010 S 104TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-2012
Practice Address - Country:US
Practice Address - Phone:414-545-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1909-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40090400Medicaid