Provider Demographics
NPI:1912674631
Name:PETSCH, BETHANY (PT, DPT)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:PETSCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1550 N WARREN AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-7800
Mailing Address - Country:US
Mailing Address - Phone:262-352-9309
Mailing Address - Fax:
Practice Address - Street 1:13203 GLOBE DR STE 111
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1616
Practice Address - Country:US
Practice Address - Phone:262-287-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15582-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist