Provider Demographics
NPI:1730852120
Name:FENTON, EMILY (DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:ANDROSCHKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:900 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6944
Mailing Address - Country:US
Mailing Address - Phone:920-787-6900
Mailing Address - Fax:
Practice Address - Street 1:900 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6944
Practice Address - Country:US
Practice Address - Phone:920-787-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15451-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100177798Medicaid