Provider Demographics
NPI:1508173642
Name:SIMON, SARA (OTR)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:SIMON
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 1:3089 NUTHATCH LANE
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153
Mailing Address - Country:US
Mailing Address - Phone:920-680-7014
Mailing Address - Fax:
Practice Address - Street 1:701 N. LAKE STREET
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157
Practice Address - Country:US
Practice Address - Phone:715-582-3962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4873-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist