# GREAT LAKES PHYSICAL THERAPY, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1124105028
- **Authorized official:** MR. JOE E MOORE P.T (OWNER)
- **Authorized official phone:** (920) 208-3557

## Contact information

- **Practice address:** 3303 SUPERIOR AVE, SHEBOYGAN, WI 53081-1861
- **Practice address phone:** (920) 208-3557
- **Practice address fax:** (920) 208-3527
- **Mailing address:** 3303 SUPERIOR AVE, SHEBOYGAN, WI 53081-1861
- **Mailing address phone:** (920) 208-3557
- **Mailing address fax:** (920) 208-3527

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | — | NULL | Yes |
| 225100000X | Physical Therapist | — | — | Yes |

## Other

- **Enumeration date:** 11/01/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 40420500 | — | WI |
| 01 | — | 7725040 | AETNA | WI |