Provider Demographics
NPI:1265489454
Name:BRATH, VIRGINIA A (OTR)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:A
Last Name:BRATH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:A
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:7517 W COLDSPRING RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-2814
Mailing Address - Country:US
Mailing Address - Phone:920-857-8311
Mailing Address - Fax:
Practice Address - Street 1:7517 W COLDSPRING RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-2814
Practice Address - Country:US
Practice Address - Phone:920-857-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1858-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40861400Medicaid