Basic Information
| Provider Information | |||||||||
| NPI: | 1164035911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKRUT | ||||||||
| FirstName: | LEAH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 26TH ST S | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546017912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629499907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2448 S 102ND ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143292500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 3087-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.