Provider Demographics
NPI:1316170814
Name:MARCELLO, DIANE KAY (PTA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KAY
Last Name:MARCELLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5473 BARLEY RD
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-3451
Mailing Address - Country:US
Mailing Address - Phone:262-742-4773
Mailing Address - Fax:
Practice Address - Street 1:211 S CURTIS ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2052
Practice Address - Country:US
Practice Address - Phone:262-248-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI962-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316170814Medicaid