Provider Demographics
NPI:1013211325
Name:TOBIANSKI, GWEN ELLEN (MS/OTR)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:ELLEN
Last Name:TOBIANSKI
Suffix:
Gender:F
Credentials:MS/OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3387 STRANGE RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53035-9649
Mailing Address - Country:US
Mailing Address - Phone:414-550-5966
Mailing Address - Fax:
Practice Address - Street 1:W3387 STRANGE RD
Practice Address - Street 2:
Practice Address - City:IRON RIDGE
Practice Address - State:WI
Practice Address - Zip Code:53035-9649
Practice Address - Country:US
Practice Address - Phone:414-550-5966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3945-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist