Provider Demographics
NPI:1306057575
Name:RISLER, TIMOTHY ALAN (PT, LAT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:RISLER
Suffix:
Gender:M
Credentials:PT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8633 32ND AVE
Practice Address - Street 2:REHAB DEPT
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-5187
Practice Address - Country:US
Practice Address - Phone:262-694-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10185-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36139600Medicaid