Provider Demographics
NPI:1164383345
Name:GRUBEN, LYDIA (PT, DPT, LMT)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:GRUBEN
Suffix:
Gender:F
Credentials:PT, DPT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18450 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-8737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1217 14TH AVE
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1695
Practice Address - Country:US
Practice Address - Phone:715-933-4784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-18
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17506-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist