=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962787218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL M. KLICKA LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2011
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BELLIN HEALTH 1970 S. RIDGE RD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-430-4888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 22ND AVE
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53566-1569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1158-39
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------