Provider Demographics
NPI:1336314129
Name:GAPEN, PATTY (COTA)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:GAPEN
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 1:1042 S BIRON DR
Mailing Address - Street 2:
Mailing Address - City:WISC RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-8257
Mailing Address - Country:US
Mailing Address - Phone:715-570-7709
Mailing Address - Fax:715-570-7709
Practice Address - Street 1:BETHEL CENTER 18014 BETHEL RD
Practice Address - Street 2:
Practice Address - City:ARPIN
Practice Address - State:WI
Practice Address - Zip Code:54410
Practice Address - Country:US
Practice Address - Phone:715-652-2103
Practice Address - Fax:715-652-2103
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI279-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI407-05-300Medicaid