Provider Demographics
NPI:1629214630
Name:SPAETH, REBECCA J (COTA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:SPAETH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W CARROLL STREET
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901
Mailing Address - Country:US
Mailing Address - Phone:815-651-0230
Mailing Address - Fax:
Practice Address - Street 1:130 W CARROLL ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1716
Practice Address - Country:US
Practice Address - Phone:815-651-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4609027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant