Provider Demographics
NPI:1427564863
Name:SPRINGSTROH, MATAYLA
Entity Type:Individual
Prefix:
First Name:MATAYLA
Middle Name:
Last Name:SPRINGSTROH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 E WYNDMERE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7147
Mailing Address - Country:US
Mailing Address - Phone:920-585-0789
Mailing Address - Fax:
Practice Address - Street 1:509 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-836-5152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer