Provider Demographics
NPI:1316389786
Name:COYLE, SUSAN M (COTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:COYLE
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 1:12 CENTURY CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-6403
Mailing Address - Country:US
Mailing Address - Phone:920-740-8441
Mailing Address - Fax:
Practice Address - Street 1:2305 SAN LUIS PL
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5211
Practice Address - Country:US
Practice Address - Phone:920-494-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI183-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI183-27OtherWI LICENSE