Provider Demographics
NPI:1679747877
Name:MEEHAN, JULIE A (PTA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:MEEHAN
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 1:729 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2745
Mailing Address - Country:US
Mailing Address - Phone:715-362-5583
Mailing Address - Fax:
Practice Address - Street 1:729 PARK ST
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2745
Practice Address - Country:US
Practice Address - Phone:715-362-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1292-019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40480500Medicaid