Healthcare Provider Details

I. General information

NPI: 1215172358
Provider Name (Legal Business Name): CHRISTINE A KOTH MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINE A MISORA MPT

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 WOODGATE DR
JANESVILLE WI
53546-8205
US

IV. Provider business mailing address

4139 WINDMILL LN
JANESVILLE WI
53546-4206
US

V. Phone/Fax

Practice location:
  • Phone: 608-359-1737
  • Fax:
Mailing address:
  • Phone: 608-359-1737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6430-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: