Provider Demographics
NPI:1629723424
Name:SHANTZ, ASHLEA (BA, COTA/L)
Entity Type:Individual
Prefix:
First Name:ASHLEA
Middle Name:
Last Name:SHANTZ
Suffix:
Gender:F
Credentials:BA, COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 S FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6498
Mailing Address - Country:US
Mailing Address - Phone:608-819-6394
Mailing Address - Fax:
Practice Address - Street 1:2927 S FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-6498
Practice Address - Country:US
Practice Address - Phone:608-819-6394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224Z00000X
3747P1801X
WI7037-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant