Provider Demographics
NPI:1114635745
Name:VAN WIE, MARLA KAY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:KAY
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6304 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-9758
Mailing Address - Country:US
Mailing Address - Phone:715-218-5452
Mailing Address - Fax:
Practice Address - Street 1:726 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2419
Practice Address - Country:US
Practice Address - Phone:715-218-5452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty