Provider Demographics
NPI:1003023433
Name:DERY, PAUL JOSEPH (COTA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:JOSEPH
Last Name:DERY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 15TH ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-2656
Mailing Address - Country:US
Mailing Address - Phone:715-839-9127
Mailing Address - Fax:
Practice Address - Street 1:2512 NEW PINE DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-1378
Practice Address - Country:US
Practice Address - Phone:715-833-0400
Practice Address - Fax:715-833-0397
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI871-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40880800Medicaid