Provider Demographics
NPI:1700451473
Name:MOLDENHAUER, NICOLE SUSETTE (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUSETTE
Last Name:MOLDENHAUER
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 1:5904 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-7413
Mailing Address - Country:US
Mailing Address - Phone:651-380-4866
Mailing Address - Fax:
Practice Address - Street 1:1800 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2008
Practice Address - Country:US
Practice Address - Phone:651-380-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3163-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant