Provider Demographics
NPI:1073704441
Name:DAHLE, DANIEL ROGERS (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ROGERS
Last Name:DAHLE
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7802
Mailing Address - Country:US
Mailing Address - Phone:920-733-7726
Mailing Address - Fax:
Practice Address - Street 1:3916 N. INTERTECH COURT
Practice Address - Street 2:SUITE B
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913
Practice Address - Country:US
Practice Address - Phone:920-733-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6442-024225100000X
WI361-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36105000Medicaid