Provider Demographics
NPI:1376614909
Name:KOTH, CATHERINE MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:MARIE
Last Name:KOTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 E KING RD
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-2004
Mailing Address - Country:US
Mailing Address - Phone:715-453-4646
Mailing Address - Fax:
Practice Address - Street 1:202 W MOHAWK DR
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2215
Practice Address - Country:US
Practice Address - Phone:715-453-7600
Practice Address - Fax:715-453-6403
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI381-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40336300Medicaid