Provider Demographics
NPI:1326214933
Name:MIDTHUN, RENEE LORRAINE (OTR)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:LORRAINE
Last Name:MIDTHUN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12476 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-5309
Mailing Address - Country:US
Mailing Address - Phone:715-462-4400
Mailing Address - Fax:
Practice Address - Street 1:12476 W LAKE ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5309
Practice Address - Country:US
Practice Address - Phone:715-462-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI686-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40518400Medicaid