Provider Demographics
NPI:1184814345
Name:PROACTIVE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY PC
Other - Org Name:PROACTIVE REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:307-367-6236
Mailing Address - Street 1:PO BOX 1037
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-1037
Mailing Address - Country:US
Mailing Address - Phone:307-367-6236
Mailing Address - Fax:307-367-3332
Practice Address - Street 1:317 N FALER AVE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-6236
Practice Address - Fax:307-367-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1163001OtherBLUE CROSS BLUE SHIELD
WY1163001OtherBLUE CROSS BLUE SHIELD