Provider Demographics
NPI:1043636889
Name:PACK, SHARI MARIE (COTA)
Entity Type:Individual
Prefix:MS
First Name:SHARI
Middle Name:MARIE
Last Name:PACK
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 1:517 EAST NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533
Mailing Address - Country:US
Mailing Address - Phone:608-574-0216
Mailing Address - Fax:
Practice Address - Street 1:7517 W COLDSPRING RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-2814
Practice Address - Country:US
Practice Address - Phone:414-327-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1700-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant