Healthcare Provider Details

I. General information

NPI: 1659283430
Provider Name (Legal Business Name): KRISTIN PROCHASKA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CLARK ST
LODI WI
53555-1010
US

IV. Provider business mailing address

812 BLUE MOUNDS ST APT 3
MOUNT HOREB WI
53572-3359
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-3241
  • Fax:
Mailing address:
  • Phone: 608-604-7647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: