Healthcare Provider Details

I. General information

NPI: 1215296249
Provider Name (Legal Business Name): MARIA KOHLWEY LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N GRANDVIEW BLVD STE. 100
PEWAUKEE WI
53072-5546
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 262-574-5185
  • Fax:
Mailing address:
  • Phone: 630-296-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1038-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: