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General NPI Number Information
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NPI Number | 1073881504
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Entity Type | Individual
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Provider Name | LORI BOBOLZ
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Gender | Female
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Dates
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Enumeration Date | 12/12/2011
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Last Update Date | 12/12/2011
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Provider Practice Location Address
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Address Line | 2448 S 102ND ST SUITE 340
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City | MILWAUKEE
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State | WI
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Zip | 53227-2466
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Country | US
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Telephone | 414-329-2430
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Fax |
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Provider Business Mailing Address
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Address Line | 2404 HAWTHORNE AVE 53545
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City | JANESVILLE
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State | WI
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Zip | 53545-1310
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Country | US
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Telephone | 608-757-1973
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 354-27
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License Number State | WI
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