Provider Demographics
NPI:1033290598
Name:MIKE, MICHAEL J (OTR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MIKE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAPLE STREET
Mailing Address - Street 2:PO BOX 470
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-0470
Mailing Address - Country:US
Mailing Address - Phone:715-356-8000
Mailing Address - Fax:
Practice Address - Street 1:240 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-0470
Practice Address - Country:US
Practice Address - Phone:715-356-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4379-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist