Provider Demographics
NPI:1720145402
Name:MEHLOS, JUDITH M (PT)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:M
Last Name:MEHLOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:BRANDHAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1539
Mailing Address - Country:US
Mailing Address - Phone:608-356-1480
Mailing Address - Fax:608-356-1446
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1539
Practice Address - Country:US
Practice Address - Phone:608-356-1480
Practice Address - Fax:608-356-1446
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3469024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40169100Medicaid