Provider Demographics
NPI:1508021031
Name:WIEDENBECK, DONNA MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:WIEDENBECK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:ANECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY SUITE 100
Mailing Address - Street 2:CONSONUS HEALTHCARE SERVICES
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5167
Mailing Address - Fax:971-206-5209
Practice Address - Street 1:4560 SE INTERNATIONAL WAY SUITE 100
Practice Address - Street 2:CONSONUS HEALTHCARE SERVICES
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-5167
Practice Address - Fax:971-206-5209
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI256-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant