Provider Demographics
NPI:1174609697
Name:LEE, BETH ANN (DPT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:LEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:MULEAHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:494 BASSWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-845-2274
Mailing Address - Fax:
Practice Address - Street 1:411 PRAIRIE HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-848-6628
Practice Address - Fax:608-848-6629
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10498-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40464000Medicaid