Provider Demographics
NPI:1073786968
Name:BOEHNLEIN, PETER ANDREW (COTA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ANDREW
Last Name:BOEHNLEIN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 WHITE BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-3938
Mailing Address - Country:US
Mailing Address - Phone:920-766-3918
Mailing Address - Fax:
Practice Address - Street 1:1640 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3214
Practice Address - Country:US
Practice Address - Phone:920-499-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI421-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8484097171Medicaid