Provider Demographics
NPI:1447779319
Name:MARSHALL, NATHANIEL (OTD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MIWLAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215
Mailing Address - Country:US
Mailing Address - Phone:262-857-5000
Mailing Address - Fax:
Practice Address - Street 1:12500 AURORA DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1227
Practice Address - Country:US
Practice Address - Phone:262-857-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 225X00000X
WI7120225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician