Provider Demographics
NPI:1679289243
Name:LOVDAHL, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:LOVDAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 IRVING PL
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2237
Mailing Address - Country:US
Mailing Address - Phone:262-880-5669
Mailing Address - Fax:
Practice Address - Street 1:410 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DOUSMAN
Practice Address - State:WI
Practice Address - Zip Code:53118-8853
Practice Address - Country:US
Practice Address - Phone:800-848-5306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2750225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant