Provider Demographics
NPI:1447545439
Name:LODAHL, MIA A (PT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:A
Last Name:LODAHL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:A
Other - Last Name:KRACKOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2600 RIB MOUNTAIN DR STE 220
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-7196
Mailing Address - Country:US
Mailing Address - Phone:715-843-5300
Mailing Address - Fax:715-843-5329
Practice Address - Street 1:2600 RIB MOUNTAIN DR STE 220
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-7196
Practice Address - Country:US
Practice Address - Phone:715-843-5300
Practice Address - Fax:715-843-5329
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11719024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526595OtherMEDICARE ORF PROVIDER NUMBER