Provider Demographics
NPI:1730692880
Name:SIDLAUSKAS, ASHLEY (PTA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SIDLAUSKAS
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 1:2273 SAMANTHA ST APT 101
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7401
Mailing Address - Country:US
Mailing Address - Phone:920-362-4237
Mailing Address - Fax:920-803-1622
Practice Address - Street 1:2131 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-5656
Practice Address - Country:US
Practice Address - Phone:920-803-1617
Practice Address - Fax:920-803-1622
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2689225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant