Provider Demographics
NPI:1922271949
Name:RAIVALA, JERAN MARIE (LPTA)
Entity Type:Individual
Prefix:MISS
First Name:JERAN
Middle Name:MARIE
Last Name:RAIVALA
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-6056
Mailing Address - Country:US
Mailing Address - Phone:218-391-8788
Mailing Address - Fax:
Practice Address - Street 1:6630 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-6056
Practice Address - Country:US
Practice Address - Phone:218-391-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1169-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicaid