Provider Demographics
NPI:1487028890
Name:GONSKA, HEATHER DANIELLE (COTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DANIELLE
Last Name:GONSKA
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 1:1204 SHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1969
Mailing Address - Country:US
Mailing Address - Phone:920-220-1127
Mailing Address - Fax:
Practice Address - Street 1:1204 SHERWOOD LN
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1969
Practice Address - Country:US
Practice Address - Phone:920-220-1127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5421-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant