| Doctor Name: | MR. TIMOTHY JOHN PROVENCHER |
| NPI Number: | 1295755890 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | P.T. |
| License Number: | 4146 |
| Business Practice Address: | 7269 Highway 60 Suite 1 Cedarburg, WI - 53012 |
| Business Phone Number: | 2623778350 |
| Business Fax Number: | 2623778390 |
| Mailing Address: | 7269 Highway 60, Suite 1 CEDARBURG |
| State: | WI |
| Postal Code: | 53012 |
| Phone Number: | 2623778350 |
| Fax Number: | 2623778390 |
| NPI Enumeration Date: | 07/20/2006 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 4146 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |