Provider Demographics
NPI:1306680392
Name:BREAKER, ELISABETH (LAT, ATC, PES)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:BREAKER
Suffix:
Gender:F
Credentials:LAT, ATC, PES
Other - Prefix:
Other - First Name:LIBBEY
Other - Middle Name:
Other - Last Name:BREAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT, ATC, PES
Mailing Address - Street 1:1650 S 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-7316
Mailing Address - Country:US
Mailing Address - Phone:920-574-5240
Mailing Address - Fax:
Practice Address - Street 1:1650 S 41ST ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-7316
Practice Address - Country:US
Practice Address - Phone:920-574-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2454-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer