Provider Demographics
NPI:1073824595
Name:MAYER, THERESA RITA (OTR)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:RITA
Last Name:MAYER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:RITA
Other - Last Name:MOES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:N2598 STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1652
Practice Address - Country:US
Practice Address - Phone:920-830-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4880026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist