Provider Demographics
NPI:1073863171
Name:WEISENBERGER, NICOLE (OTR)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:WEISENBERGER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N BREARLY ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1601
Mailing Address - Country:US
Mailing Address - Phone:608-345-2670
Mailing Address - Fax:
Practice Address - Street 1:2927 S FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-6498
Practice Address - Country:US
Practice Address - Phone:608-819-6394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-16
Last Update Date:2012-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4075-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist