Provider Demographics
NPI:1275801987
Name:KNUTH, SUSAN JOAN (OTR/L, ATP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JOAN
Last Name:KNUTH
Suffix:
Gender:F
Credentials:OTR/L, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3341
Mailing Address - Country:US
Mailing Address - Phone:920-729-5658
Mailing Address - Fax:
Practice Address - Street 1:1800 APPLETON RD
Practice Address - Street 2:EARLY INTERVENTION SERVICES
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-3727
Practice Address - Country:US
Practice Address - Phone:920-968-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1625-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1625-26OtherSTATE OF WISCONSIN DEPT OF REGULATION AND LICENSING
WI812OtherWISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION - OCCUPATIONAL THERAPY
WI808OtherWISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION - EARLY CHILDHOOD EXCEPTIONAL ED NEED