Provider Demographics
NPI:1649567850
Name:SWIETER, CONSTANCE MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:MARIE
Last Name:SWIETER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:CONSTANCE
Other - Middle Name:MARIE
Other - Last Name:TALLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:320 STATE ST
Mailing Address - Street 2:APT. 9
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9167
Mailing Address - Country:US
Mailing Address - Phone:262-903-6567
Mailing Address - Fax:
Practice Address - Street 1:320 STATE ST
Practice Address - Street 2:APT. 9
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9167
Practice Address - Country:US
Practice Address - Phone:262-903-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4739-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant