Provider Demographics
NPI:1093846339
Name:PRIBYL, SUSAN LAURA (COTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LAURA
Last Name:PRIBYL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LAURA
Other - Last Name:WURTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:E1097 PRIBYL RD
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:WI
Mailing Address - Zip Code:54208-7767
Mailing Address - Country:US
Mailing Address - Phone:920-776-1095
Mailing Address - Fax:
Practice Address - Street 1:5000 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3900
Practice Address - Country:US
Practice Address - Phone:920-794-5176
Practice Address - Fax:920-794-5472
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI502-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40271900Medicaid