Provider Demographics
NPI:1457642779
Name:DIEHL, ANDREA NICOLE WOLOSZ
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE WOLOSZ
Last Name:DIEHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 OVERLOOK TER
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2254
Mailing Address - Country:US
Mailing Address - Phone:608-256-1901
Mailing Address - Fax:608-203-4544
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:608-203-4544
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5017-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5017-023OtherOCCUPTATIONAL THERAPIST