Provider Demographics
NPI:1891044103
Name:EDDY, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:EDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S HOLMEN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9467
Mailing Address - Country:US
Mailing Address - Phone:608-526-9888
Mailing Address - Fax:608-526-9965
Practice Address - Street 1:620 GRAND VIEW AVE
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616
Practice Address - Country:US
Practice Address - Phone:608-989-2195
Practice Address - Fax:608-989-2265
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI492427224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant