Provider Demographics
NPI:1881964229
Name:FLOCK, LOIS L (PTA)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:L
Last Name:FLOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-1726
Mailing Address - Country:US
Mailing Address - Phone:608-366-6239
Mailing Address - Fax:
Practice Address - Street 1:331 S WATER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1726
Practice Address - Country:US
Practice Address - Phone:608-366-6239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI798-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI225200000XOtherPRIVATE INSURANCE