Provider Demographics
NPI:1003029406
Name:HERWIG, MANDI ANN (COTA)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:ANN
Last Name:HERWIG
Suffix:
Gender:F
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:N7584 STONEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9149
Mailing Address - Country:US
Mailing Address - Phone:608-742-3067
Mailing Address - Fax:
Practice Address - Street 1:323 WEST MONROE STREET
Practice Address - Street 2:
Practice Address - City:WYOCENA
Practice Address - State:WI
Practice Address - Zip Code:53969
Practice Address - Country:US
Practice Address - Phone:608-429-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1361-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant