Provider Demographics
NPI:1811507197
Name:ZOGLMAN, MALORY (PT)
Entity type:Individual
Prefix:
First Name:MALORY
Middle Name:
Last Name:ZOGLMAN
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 1:1000 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1116
Mailing Address - Country:US
Mailing Address - Phone:920-257-2000
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:4000 N PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8018
Practice Address - Country:US
Practice Address - Phone:920-968-0814
Practice Address - Fax:920-734-6159
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14435-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist