Provider Demographics
NPI:1043798341
Name:MATHWICH, TIA (PT)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:MATHWICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:314 HICKORY CT
Mailing Address - Street 2:
Mailing Address - City:ORFORDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53576-9599
Mailing Address - Country:US
Mailing Address - Phone:608-295-1705
Mailing Address - Fax:
Practice Address - Street 1:707 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3027
Practice Address - Country:US
Practice Address - Phone:920-887-7181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14176-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist