Provider Demographics
NPI:1831592708
Name:LILIEDAHL-MATIYOW, STACI (DPT)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:LILIEDAHL-MATIYOW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9004
Mailing Address - Country:US
Mailing Address - Phone:712-329-9419
Mailing Address - Fax:712-329-0329
Practice Address - Street 1:201 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9004
Practice Address - Country:US
Practice Address - Phone:712-329-9419
Practice Address - Fax:712-329-0329
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03634225100000X
NE2218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist