Provider Demographics
NPI:1053543355
Name:NEUBAUER, LORI JO
Entity type:Individual
Prefix:
First Name:LORI JO
Middle Name:
Last Name:NEUBAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORI JO
Other - Middle Name:
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:1707 OAK ST STE D
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-2125
Mailing Address - Country:US
Mailing Address - Phone:406-579-4802
Mailing Address - Fax:
Practice Address - Street 1:1707 OAK ST STE D
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2125
Practice Address - Country:US
Practice Address - Phone:406-579-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2254PTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant