Provider Demographics
NPI:1144434168
Name:DODGE, DEANNA MARIE (PTA)
Entity type:Individual
Prefix:MISS
First Name:DEANNA
Middle Name:MARIE
Last Name:DODGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 S PARKNOLL DR
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-3436
Mailing Address - Country:US
Mailing Address - Phone:262-914-3764
Mailing Address - Fax:
Practice Address - Street 1:3821 S CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-3712
Practice Address - Country:US
Practice Address - Phone:414-762-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI522019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36106700Medicaid