Provider Demographics
NPI:1679615934
Name:NIEBUHR, MARK A (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:NIEBUHR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2170
Mailing Address - Country:US
Mailing Address - Phone:608-269-2132
Mailing Address - Fax:
Practice Address - Street 1:310 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54665-2170
Practice Address - Country:US
Practice Address - Phone:608-269-2132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3134-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist