Provider Demographics
NPI:1609093194
Name:DAIGNEAULT, DEIDRI (OTR)
Entity Type:Individual
Prefix:
First Name:DEIDRI
Middle Name:
Last Name:DAIGNEAULT
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 1:31509 NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-2802
Mailing Address - Country:US
Mailing Address - Phone:262-534-6843
Mailing Address - Fax:
Practice Address - Street 1:1701 SHARP RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-5214
Practice Address - Country:US
Practice Address - Phone:262-534-7297
Practice Address - Fax:262-534-7257
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1263-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist