Provider Demographics
NPI:1396379954
Name:NEEDHAM, CHAD J (LMT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 E DIVISION ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-1385
Mailing Address - Country:US
Mailing Address - Phone:608-344-1902
Mailing Address - Fax:
Practice Address - Street 1:101 1/2 S WATER ST LOWR UNIT
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1722
Practice Address - Country:US
Practice Address - Phone:608-344-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-23
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12814-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist