1578711149 NPI number — HEATHER MARIA STAHL C.O.T.A.

Table of content: HEATHER MARIA STAHL C.O.T.A. (NPI 1578711149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578711149 NPI number — HEATHER MARIA STAHL C.O.T.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAHL
Provider First Name:
HEATHER
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C.O.T.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUFF
Provider Other First Name:
HEATHER
Provider Other Middle Name:
MARIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
C.O.T.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578711149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
891 W PINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSCODA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53573-9312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-604-5370
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 WARD ST
Provider Second Line Business Practice Location Address:
SALUCARE
Provider Business Practice Location Address City Name:
LACROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-787-8200
Provider Business Practice Location Address Fax Number:
608-787-8211
Provider Enumeration Date:
09/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , with the licence number:  403-027 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)