Provider Demographics
NPI:1487988432
Name:RISSE, ABBY LYNN (PT)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:LYNN
Last Name:RISSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 1ST ST
Mailing Address - Street 2:
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1772
Mailing Address - Country:US
Mailing Address - Phone:920-994-9700
Mailing Address - Fax:920-994-4606
Practice Address - Street 1:402 1ST ST
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1772
Practice Address - Country:US
Practice Address - Phone:920-994-9700
Practice Address - Fax:920-994-4606
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11323-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WINA APPLICATION PENDMedicaid