Provider Demographics
NPI:1104191824
Name:DORAISWAMY, DEANNA P (OT)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:P
Last Name:DORAISWAMY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 E PLANK RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7045
Mailing Address - Country:US
Mailing Address - Phone:920-655-7340
Mailing Address - Fax:
Practice Address - Street 1:2961 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-468-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4982-026225X00000X
VA0119005787225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI002150302Medicare Oscar/Certification
WIWI1097026Medicare Oscar/Certification