Provider Demographics
NPI:1750502035
Name:SPECKBROCK, PAMELA SUE (OTR)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUE
Last Name:SPECKBROCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5212 MESA RD
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2915
Mailing Address - Country:US
Mailing Address - Phone:608-221-8275
Mailing Address - Fax:
Practice Address - Street 1:901 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1335
Practice Address - Country:US
Practice Address - Phone:920-648-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3103026225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40853500Medicaid