Provider Demographics
NPI:1336312396
Name:HOLMGREEN, LORI L (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:HOLMGREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:HOLMGREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:W9609 GAYLORD RD
Mailing Address - Street 2:
Mailing Address - City:MERRILLAN
Mailing Address - State:WI
Mailing Address - Zip Code:54754-7926
Mailing Address - Country:US
Mailing Address - Phone:715-333-5011
Mailing Address - Fax:
Practice Address - Street 1:W9609 GAYLORD RD
Practice Address - Street 2:
Practice Address - City:MERRILLAN
Practice Address - State:WI
Practice Address - Zip Code:54754-7926
Practice Address - Country:US
Practice Address - Phone:715-333-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI238-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant