Provider Demographics
NPI:1285474924
Name:MAATTA, DANIEL BRUCE
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:BRUCE
Last Name:MAATTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4970
Mailing Address - Country:US
Mailing Address - Phone:715-401-9102
Mailing Address - Fax:
Practice Address - Street 1:501 GOPHER DR
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4513
Practice Address - Country:US
Practice Address - Phone:608-372-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16748-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist