Provider Demographics
NPI:1306051743
Name:DIETENBERGER, AGNES P (PTA, CMT)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:P
Last Name:DIETENBERGER
Suffix:
Gender:F
Credentials:PTA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-2790
Mailing Address - Country:US
Mailing Address - Phone:262-673-0142
Mailing Address - Fax:
Practice Address - Street 1:1640 E. SUMNER ST.
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027
Practice Address - Country:US
Practice Address - Phone:262-670-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant