Provider Demographics
NPI:1962161331
Name:MODAHL, SANDRA LYNN
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LYNN
Last Name:MODAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 SPINNAKER DR
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1389
Mailing Address - Country:US
Mailing Address - Phone:414-640-9646
Mailing Address - Fax:
Practice Address - Street 1:1000 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3533
Practice Address - Country:US
Practice Address - Phone:414-479-9233
Practice Address - Fax:414-259-0575
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist