Healthcare Provider Details

I. General information

NPI: 1316826191
Provider Name (Legal Business Name): LYDIA PEREZ KOCIS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

1697 FULHAM ST APT D
LAUDERDALE MN
55113-5248
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17943-24
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14099
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2025-0350
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: