Provider Demographics
NPI:1306871520
Name:DAHL, RANDY THOMAS (OTR)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:THOMAS
Last Name:DAHL
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5053
Mailing Address - Country:US
Mailing Address - Phone:262-241-9224
Mailing Address - Fax:262-241-9228
Practice Address - Street 1:1535 W MARKET ST
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5053
Practice Address - Country:US
Practice Address - Phone:262-241-9224
Practice Address - Fax:262-241-9228
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3576-026225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40195003Medicare ID - Type Unspecified