Provider Demographics
NPI:1407952526
Name:DYBUL, LAURIE (PT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:DYBUL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 SAINT ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53021-9479
Mailing Address - Country:US
Mailing Address - Phone:262-483-3625
Mailing Address - Fax:
Practice Address - Street 1:10602 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5079
Practice Address - Country:US
Practice Address - Phone:262-241-8030
Practice Address - Fax:262-241-8304
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9880-0242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics