Provider Demographics
NPI:1689761116
Name:KNICKREHM, RONALD DALE (PT)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DALE
Last Name:KNICKREHM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 SWANSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350
Mailing Address - Country:US
Mailing Address - Phone:219-324-4106
Mailing Address - Fax:
Practice Address - Street 1:2102 EAST EVANS AVENUE
Practice Address - Street 2:SUITE 115
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4096
Practice Address - Country:US
Practice Address - Phone:219-476-0377
Practice Address - Fax:219-476-0388
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001536A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000202146OtherANTHEM
000000202146OtherANTHEM
S95658Medicare UPIN