Basic Information
| Provider Information | |||||||||
| NPI: | 1073881504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOBOLZ | ||||||||
| FirstName: | LORI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2404 HAWTHORNE AVE | ||||||||
| Address2: | 53545 | ||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535451310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087571973 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2448 S 102ND ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143292430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2011 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 354-27 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.