Provider Demographics
NPI:1376743385
Name:WENZEL, MARCIE MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARCIE
Middle Name:MARIE
Last Name:WENZEL
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:W10633 CASCADE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9631
Mailing Address - Country:US
Mailing Address - Phone:608-742-0441
Mailing Address - Fax:
Practice Address - Street 1:700 CLARK ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1010
Practice Address - Country:US
Practice Address - Phone:608-592-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1349027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant