Provider Demographics
NPI:1487755021
Name:LEEAN-RODENZ, MIRIAM JOY (DC)
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:JOY
Last Name:LEEAN-RODENZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MIRIAM
Other - Middle Name:J
Other - Last Name:LEEAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:304 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-5703
Mailing Address - Country:US
Mailing Address - Phone:715-258-8211
Mailing Address - Fax:715-258-0118
Practice Address - Street 1:304 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-5703
Practice Address - Country:US
Practice Address - Phone:715-258-8211
Practice Address - Fax:715-258-0118
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3651-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38934000Medicaid
WI000435415Medicare ID - Type Unspecified
WIU80350Medicare UPIN