Provider Demographics
NPI:1437281599
Name:CARRIVEAU, MISTY M (OTR)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:M
Last Name:CARRIVEAU
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:W 7061 OLD W ROAD
Mailing Address - Street 2:PO BOX 414
Mailing Address - City:CRIVITZ
Mailing Address - State:WI
Mailing Address - Zip Code:54114
Mailing Address - Country:US
Mailing Address - Phone:715-854-8294
Mailing Address - Fax:
Practice Address - Street 1:4061 OLD PESHTIGO RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3887
Practice Address - Country:US
Practice Address - Phone:715-732-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3734225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40840700Medicare ID - Type Unspecified