Basic Information
Provider Information | |||||||||
NPI: | 1801493325 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIDIE | ||||||||
FirstName: | HALEY | ||||||||
MiddleName: | EVELYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CTRS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SNYDER | ||||||||
OtherFirstName: | HALEY | ||||||||
OtherMiddleName: | EVELYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CTRS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | W7628 22ND ST W | ||||||||
Address2: |   | ||||||||
City: | NECEDAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546467704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 E VETERANS ST | ||||||||
Address2: |   | ||||||||
City: | TOMAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546603105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083723971 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2020 | ||||||||
LastUpdateDate: | 10/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225800000X | 82368 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist |   |
No ID Information.