Provider Demographics
NPI:1659719342
Name:POGWIZD, REBEKAH K (OT)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:K
Last Name:POGWIZD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S BARCLAY ST
Mailing Address - Street 2:APT 407
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1433
Mailing Address - Country:US
Mailing Address - Phone:715-820-1312
Mailing Address - Fax:
Practice Address - Street 1:6908 N SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:FOX POINT
Practice Address - State:WI
Practice Address - Zip Code:53217-3942
Practice Address - Country:US
Practice Address - Phone:414-352-2082
Practice Address - Fax:414-352-5279
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-010182225X00000X
WI5417-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400136056Medicare PIN
WIK400136057Medicare PIN