Provider Demographics
NPI:1417295684
Name:WENGER, RENEE JOHNSON (COTA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:JOHNSON
Last Name:WENGER
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 1:325 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-1001
Mailing Address - Country:US
Mailing Address - Phone:608-553-2247
Mailing Address - Fax:
Practice Address - Street 1:3151 COUNTY ROAD CH
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-3151
Practice Address - Country:US
Practice Address - Phone:608-935-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4972-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant