Provider Demographics
NPI:1235310921
Name:DOBBERPUHL, SUSAN ANN (OTR)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:DOBBERPUHL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:KOTECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ORT
Mailing Address - Street 1:306 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 N SPRINT ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074
Practice Address - Country:US
Practice Address - Phone:262-284-2668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1841026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40864700Medicaid