Provider Demographics
NPI:1043483860
Name:KLIKA, DIANE MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:KLIKA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1133
Mailing Address - Country:US
Mailing Address - Phone:920-229-1179
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5534
Practice Address - Fax:920-361-5190
Is Sole Proprietor?:No
Enumeration Date:2008-04-13
Last Update Date:2008-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4054-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40181000Medicaid