Basic Information
| Provider Information | |||||||||
| NPI: | 1396911335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATUSZAK | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 744 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 964 W RYAN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BRILLION | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541101076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207562055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5846-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40326300 | 05 | WI | MEDICAID |