Provider Demographics
NPI:1831294511
Name:MOOTZ, DEANNA LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:LYNN
Last Name:MOOTZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:DEANNA
Other - Middle Name:LYNN
Other - Last Name:DOERING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3541 PLOVER RD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-2155
Mailing Address - Country:US
Mailing Address - Phone:715-423-5423
Mailing Address - Fax:715-423-1532
Practice Address - Street 1:825 WHITING AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-5246
Practice Address - Country:US
Practice Address - Phone:715-346-1615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI752-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40386900Medicaid