Provider Demographics
NPI:1043571896
Name:DART, LORI B (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:B
Last Name:DART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:B
Other - Last Name:BRUNNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1300 EGG HARBOR RD STE 108
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1284
Mailing Address - Country:US
Mailing Address - Phone:920-746-0410
Mailing Address - Fax:
Practice Address - Street 1:1300 EGG HARBOR RD STE 108
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1284
Practice Address - Country:US
Practice Address - Phone:920-746-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12032-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12032-024OtherWI LICENSE