Provider Demographics
NPI:1528346897
Name:TALATZKO, SHANNON M (DPT)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:M
Last Name:TALATZKO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:BARTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:W165S7431 BELLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8840
Mailing Address - Country:US
Mailing Address - Phone:414-412-5370
Mailing Address - Fax:
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:EAST SIDE BLDG
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9694
Practice Address - Country:US
Practice Address - Phone:414-647-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11732-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist