Provider Demographics
NPI:1609040476
Name:KACZMAREK, DIANNA (OTR)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:KACZMAREK
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 1:5604 APRICOT CT
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1711
Mailing Address - Country:US
Mailing Address - Phone:414-421-2636
Mailing Address - Fax:
Practice Address - Street 1:9244 29TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6602
Practice Address - Country:US
Practice Address - Phone:262-694-0080
Practice Address - Fax:262-942-7395
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2689-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41811700Medicaid