Healthcare Provider Details

I. General information

NPI: 1376614909
Provider Name (Legal Business Name): CATHERINE MARIE KOTH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W MOHAWK DR
TOMAHAWK WI
54487-2215
US

IV. Provider business mailing address

1255 E KING RD
TOMAHAWK WI
54487-2004
US

V. Phone/Fax

Practice location:
  • Phone: 715-453-7600
  • Fax: 715-453-6403
Mailing address:
  • Phone: 715-453-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number381-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: