Provider Demographics
NPI:1043517238
Name:IMHOFF, DIANE M (PTA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:IMHOFF
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:KIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:700 WEST AVENUE S.
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-392-9768
Mailing Address - Fax:608-392-7124
Practice Address - Street 1:700 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4783
Practice Address - Country:US
Practice Address - Phone:608-392-9768
Practice Address - Fax:608-392-7124
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1014225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant