Provider Demographics
NPI:1508923053
Name:KIECKER, EMMY (OTR)
Entity Type:Individual
Prefix:
First Name:EMMY
Middle Name:
Last Name:KIECKER
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 1:1405 MILL ST
Mailing Address - Street 2:REHAB DEPARTMENT
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2155
Mailing Address - Country:US
Mailing Address - Phone:920-531-2031
Mailing Address - Fax:
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:REHAB DEPARTMENT
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1069197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist