Provider Demographics
NPI:1407222540
Name:YATA, MARA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:LYNN
Last Name:YATA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:LYNN
Other - Last Name:STOFFEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-586-5710
Mailing Address - Fax:414-586-5740
Practice Address - Street 1:7878 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-3914
Practice Address - Country:US
Practice Address - Phone:414-586-5760
Practice Address - Fax:414-586-5740
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225100000X
WI13154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100048344Medicaid