Provider Demographics
NPI:1043649510
Name:LICH, JOHN (PTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2903
Mailing Address - Country:US
Mailing Address - Phone:800-395-5000
Mailing Address - Fax:
Practice Address - Street 1:301 LONG RAPIDS RD
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1317
Practice Address - Country:US
Practice Address - Phone:989-356-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL22574440225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant