Provider Demographics
NPI:1902475221
Name:GANCHEVA, KAMELIYA STOYANOVA (PTA)
Entity Type:Individual
Prefix:
First Name:KAMELIYA
Middle Name:STOYANOVA
Last Name:GANCHEVA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 FREY ST APT 111
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2903
Mailing Address - Country:US
Mailing Address - Phone:608-844-4145
Mailing Address - Fax:
Practice Address - Street 1:9401 OLD SAUK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-4409
Practice Address - Country:US
Practice Address - Phone:608-535-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2863-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant