Provider Demographics
NPI:1538668405
Name:GERONDALE, LYDEL MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:LYDEL
Middle Name:MARIE
Last Name:GERONDALE
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 1:1112 ROLAND LN APT 16
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-6394
Mailing Address - Country:US
Mailing Address - Phone:920-604-0631
Mailing Address - Fax:
Practice Address - Street 1:2305 SAN LUIS PL
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5211
Practice Address - Country:US
Practice Address - Phone:920-494-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2504-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant