Provider Demographics
NPI:1306350970
Name:MAULICK, TAYLER LEIGH (PTA)
Entity type:Individual
Prefix:
First Name:TAYLER
Middle Name:LEIGH
Last Name:MAULICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TAYLER
Other - Middle Name:LEIGH
Other - Last Name:WOELZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1033 S FIDELIS ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952
Practice Address - Country:US
Practice Address - Phone:920-739-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-19
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2681-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant