Provider Demographics
NPI:1104375484
Name:KRUG, MICHELLE RAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:KRUG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RAE
Other - Last Name:HENTGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:106 S HOLMEN DR STE 2
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 S HOLMEN DR STE 2
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9468
Practice Address - Country:US
Practice Address - Phone:608-526-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5908 - 26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist