Provider Demographics
NPI:1699941005
Name:DELAET, SUSAN MARIE (PTA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:DELAET
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:5700 WEST LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220
Mailing Address - Country:US
Mailing Address - Phone:414-281-7200
Mailing Address - Fax:414-282-7512
Practice Address - Street 1:5700 WEST LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220
Practice Address - Country:US
Practice Address - Phone:414-281-7200
Practice Address - Fax:414-282-7512
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI835019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40455600Medicaid