Basic Information
| Provider Information | |||||||||
| NPI: | 1588992531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROZAK | ||||||||
| FirstName: | ASHLEE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICKLE | ||||||||
| OtherFirstName: | ASHLEE | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 W. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546562170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082692132 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2009 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11312 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.