MEDICARE: DAWN NIEDFELDT LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	14012	WI

General Provider Information

NPI Number	:	1053027912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN NIEDFELDT LMT

Provider Business Mailing Address
First Line	:	122 STAFFORD ST
Second Line	:
City	:	PLYMOUTH
State	:	WI
Zip	:	53073-1810
Country	:	US
Telephone Number	:	920-254-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 E MILL ST STE 1
Second Line	:
City	:	PLYMOUTH
State	:	WI
Zip	:	53073-1840
Country	:	US
Telephone Number	:	920-254-3800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2023
Last Update Date	:	01/24/2023

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