Basic Information
| Provider Information | |||||||||
| NPI: | 1073130670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOHRER | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | KATHRYN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1731 SUNNYSIDE LN | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541153465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206769514 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3117 SHORE DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157325111 | ||||||||
| FaxNumber: | 7157328220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2020 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 15011-24 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 15011-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100100866 | 05 | WI | MEDICAID |