Provider Demographics
NPI:1679787717
Name:LEDERMAN, CYNTHHIA JO (PT)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHHIA
Middle Name:JO
Last Name:LEDERMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 URBAN RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53570-9637
Mailing Address - Country:US
Mailing Address - Phone:608-938-4645
Mailing Address - Fax:
Practice Address - Street 1:516 26TH AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1531
Practice Address - Country:US
Practice Address - Phone:608-329-6600
Practice Address - Fax:608-329-6594
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2162-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40294400Medicaid