Provider Demographics
NPI:1164855854
Name:KEITH, JULIE M (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:M
Last Name:KEITH
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:S9619 RAHL RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-9782
Mailing Address - Country:US
Mailing Address - Phone:608-643-4353
Mailing Address - Fax:
Practice Address - Street 1:333 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1914
Practice Address - Country:US
Practice Address - Phone:608-647-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI196-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant