Provider Demographics
NPI:1609040724
Name:BERKOVITZ, LORI (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BERKOVITZ
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 1:2409 WOODINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54173-7904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2409 WOODINGTON WAY
Practice Address - Street 2:
Practice Address - City:SUAMICO
Practice Address - State:WI
Practice Address - Zip Code:54173-7904
Practice Address - Country:US
Practice Address - Phone:920-434-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI115-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant