Provider Demographics
NPI:1134335839
Name:SONKOWSKY, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SONKOWSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:3389 COOKS LANE NORTH
Mailing Address - City:LONG LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54542-0071
Mailing Address - Country:US
Mailing Address - Phone:715-415-5101
Mailing Address - Fax:
Practice Address - Street 1:5778 CHAPIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-9443
Practice Address - Country:US
Practice Address - Phone:715-528-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4396-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41037800Medicaid