Provider Demographics
NPI:1689374233
Name:FULLER, ELIZABETH (COTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FULLER
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:N7040 PECK STATION RD
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-3244
Mailing Address - Country:US
Mailing Address - Phone:262-949-8456
Mailing Address - Fax:
Practice Address - Street 1:611 HARMONY DR
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-8800
Practice Address - Country:US
Practice Address - Phone:262-249-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5336224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant