Provider Demographics
NPI:1134457427
Name:BAVLNKA, ROSE (OTR)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:BAVLNKA
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:W202N10223 LANNON RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-9545
Mailing Address - Country:US
Mailing Address - Phone:262-366-9088
Mailing Address - Fax:
Practice Address - Street 1:W202N10223 LANNON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-9545
Practice Address - Country:US
Practice Address - Phone:262-366-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1036-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40523200Medicaid