Provider Demographics
NPI:1033291943
Name:CAELWAERTS, LYNN M (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:M
Last Name:CAELWAERTS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:LYNN
Other - Middle Name:M
Other - Last Name:CHERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:3100 SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-732-5111
Mailing Address - Fax:715-732-0628
Practice Address - Street 1:3117 SHORE DRIVE SUITE 101
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-732-5111
Practice Address - Fax:715-732-0628
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI139727224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40859700Medicaid
WI40859700Medicaid