Provider Demographics
NPI:1477821718
Name:JOHNSON, PAULA DUDYCHA (COTA)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:DUDYCHA
Last Name:JOHNSON
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 1:3095 85TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-4914
Mailing Address - Country:US
Mailing Address - Phone:715-327-5667
Mailing Address - Fax:
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-329-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1024-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant