Provider Demographics
NPI:1093746232
Name:ROMBACH, RENAE ANDREA (PT)
Entity Type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:ANDREA
Last Name:ROMBACH
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 1:24546 LARSON RD
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-8539
Mailing Address - Country:US
Mailing Address - Phone:715-463-5524
Mailing Address - Fax:
Practice Address - Street 1:257 W SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7827
Practice Address - Country:US
Practice Address - Phone:715-463-5353
Practice Address - Fax:715-463-2423
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9906-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40444700Medicaid