Provider Demographics
NPI:1548845837
Name:SHIMON, MICHAELA E (PTA)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:E
Last Name:SHIMON
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 1:524 E QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-1949
Mailing Address - Country:US
Mailing Address - Phone:920-366-1705
Mailing Address - Fax:
Practice Address - Street 1:1010 E WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3101
Practice Address - Country:US
Practice Address - Phone:715-842-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3150225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant