Provider Demographics
NPI:1639519713
Name:MYHRE, DIANNE L (LMT)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:L
Last Name:MYHRE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:ORFORDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53576-0014
Mailing Address - Country:US
Mailing Address - Phone:608-289-8640
Mailing Address - Fax:
Practice Address - Street 1:400 E GRAND AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6200
Practice Address - Country:US
Practice Address - Phone:608-289-8640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1900-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist