Provider Demographics
NPI:1508078312
Name:VOLLMER, SUE ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:ANN
Last Name:VOLLMER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8011 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-7813
Mailing Address - Country:US
Mailing Address - Phone:920-923-1192
Mailing Address - Fax:
Practice Address - Street 1:1610 HOOVER ST
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1636
Practice Address - Country:US
Practice Address - Phone:920-898-5627
Practice Address - Fax:920-898-1375
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3392-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41037500Medicaid