Provider Demographics
NPI:1659590370
Name:OTT, DIANE MARY (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARY
Last Name:OTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:MARY
Other - Last Name:BRUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:516 E GREEN BAY AVE
Mailing Address - Street 2:RIVERVIEW PHYSICAL THERAPY & SPORTS MEDICINE S.C.
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080
Mailing Address - Country:US
Mailing Address - Phone:262-284-9510
Mailing Address - Fax:262-284-9511
Practice Address - Street 1:516 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080
Practice Address - Country:US
Practice Address - Phone:262-284-9510
Practice Address - Fax:262-284-9511
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4345-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40377600Medicaid
WI40377600Medicaid
WI000182180Medicare PIN