Provider Demographics
NPI:1073718581
Name:LORECK, MARIE COLETTE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:COLETTE
Last Name:LORECK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2160 DEBRA CT
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1624
Mailing Address - Country:US
Mailing Address - Phone:920-849-3340
Mailing Address - Fax:
Practice Address - Street 1:7517 W COLDSPRING RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-2814
Practice Address - Country:US
Practice Address - Phone:414-327-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1092-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40070000Medicaid