Provider Demographics
NPI:1376609263
Name:WELLER, CHERYL (OTR)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:CHERYL
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:2080 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:WI
Mailing Address - Zip Code:54411
Mailing Address - Country:US
Mailing Address - Phone:715-257-1456
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4120
Practice Address - Country:US
Practice Address - Phone:715-847-2826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2086-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40832600Medicaid