Provider Demographics
NPI:1760051288
Name:FREY-MCGOVERN, COLLEEN (COTA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:FREY-MCGOVERN
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 1:7818 BIG SKY DR STE 217
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2840
Mailing Address - Country:US
Mailing Address - Phone:786-473-4758
Mailing Address - Fax:
Practice Address - Street 1:7818 BIG SKY DR STE 217
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2840
Practice Address - Country:US
Practice Address - Phone:786-473-4758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5586-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant