Basic Information
| Provider Information | |||||||||
| NPI: | 1639405723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAGEBERG | ||||||||
| FirstName: | JUANITA | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLBY | ||||||||
| OtherFirstName: | JUANITA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 HOSPITAL RD. | ||||||||
| Address2: | EAGLE RIVER MEMORIAL HOSPITAL | ||||||||
| City: | EAGLE RIVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545218835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154790224 | ||||||||
| FaxNumber: | 7154790398 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 HOSPITAL RD. | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545218835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154790224 | ||||||||
| FaxNumber: | 7154790398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2009 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4403-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1526 | ND | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 7392 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.