Provider Demographics
NPI:1346595667
Name:LODGE, KRISTA (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:WILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1111 ANSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-2248
Practice Address - Country:US
Practice Address - Phone:319-433-0130
Practice Address - Fax:319-433-0131
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12010-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist