Provider Demographics
NPI:1528714300
Name:RUTZ, SHANNON LEAH (MPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEAH
Last Name:RUTZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEAH
Other - Last Name:KVAPIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1616 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-3131
Mailing Address - Country:US
Mailing Address - Phone:715-575-3475
Mailing Address - Fax:
Practice Address - Street 1:331 S WATER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1726
Practice Address - Country:US
Practice Address - Phone:608-269-3168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9791-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist