Provider Demographics
NPI:1518903749
Name:PAULOWSKE, MICHELLE C (OT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:PAULOWSKE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:C
Other - Last Name:BLASI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:3601 30TH AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:626-657-7190
Practice Address - Street 1:8400 LAKEVIEW PARKWAY
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158
Practice Address - Country:US
Practice Address - Phone:262-697-7295
Practice Address - Fax:262-697-9412
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3855026225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40890000Medicaid