Provider Demographics
NPI:1063689487
Name:TIMM, ERIN (OTR, DPT)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:TIMM
Suffix:
Gender:F
Credentials:OTR, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:888-201-1040
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:417 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005
Practice Address - Country:US
Practice Address - Phone:715-263-4110
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4527-026225X00000X
WI11428-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063689487Medicaid
WI1063689487Medicaid
WIWI1422002Medicare PIN
P00904580Medicare PIN