Provider Demographics
NPI:1578711149
Name:STAHL, HEATHER MARIA (COTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIA
Last Name:STAHL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIA
Other - Last Name:DUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:891 W PINE RD
Mailing Address - Street 2:
Mailing Address - City:MUSCODA
Mailing Address - State:WI
Mailing Address - Zip Code:53573-9312
Mailing Address - Country:US
Mailing Address - Phone:608-604-5370
Mailing Address - Fax:
Practice Address - Street 1:2600 WARD ST
Practice Address - Street 2:SALUCARE
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-787-8200
Practice Address - Fax:608-787-8211
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI403-027251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)