Provider Demographics
NPI:1164622585
Name:TUCKER, KATHY JEANNE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:JEANNE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:KATHY
Other - Middle Name:JEANNE
Other - Last Name:SCHMITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:520 E. HOLUM STREET
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-842-6500
Mailing Address - Fax:608-837-9484
Practice Address - Street 1:1513 BOULDER WAY
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1253
Practice Address - Country:US
Practice Address - Phone:608-837-6152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI254-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40691700Medicaid