Provider Demographics
NPI:1154830818
Name:MATUSZAK, DANIELLE CLARE (COTA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:CLARE
Last Name:MATUSZAK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6091
Mailing Address - Country:US
Mailing Address - Phone:608-732-0944
Mailing Address - Fax:
Practice Address - Street 1:620 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616-5461
Practice Address - Country:US
Practice Address - Phone:608-989-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5445-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant