Provider Demographics
NPI:1376745976
Name:BARTZ-BENTZ, CAROL LYNN (OTR)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:BARTZ-BENTZ
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:E5551 STATE ROAD 161
Mailing Address - Street 2:
Mailing Address - City:MANAWA
Mailing Address - State:WI
Mailing Address - Zip Code:54949-9601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:E5551 STATE ROAD 161
Practice Address - Street 2:
Practice Address - City:MANAWA
Practice Address - State:WI
Practice Address - Zip Code:54949-9601
Practice Address - Country:US
Practice Address - Phone:920-596-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20-026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40543300Medicaid