Provider Demographics
NPI:1073881504
Name:BOBOLZ, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BOBOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 HAWTHORNE AVE
Mailing Address - Street 2:53545
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1310
Mailing Address - Country:US
Mailing Address - Phone:608-757-1973
Mailing Address - Fax:
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:SUITE 340
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-329-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI354-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant