Provider Demographics
NPI:1619488012
Name:GMACH, RAVEN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:GMACH
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ALGOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-3551
Mailing Address - Country:US
Mailing Address - Phone:920-917-5773
Mailing Address - Fax:
Practice Address - Street 1:800 ALGOMA BLVD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3551
Practice Address - Country:US
Practice Address - Phone:920-917-5773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WI2424-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2424-39OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES