Provider Demographics
NPI:1790804052
Name:FOUTCH, MARCI R (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARCI
Middle Name:R
Last Name:FOUTCH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MARCI
Other - Middle Name:R
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:412 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-5311
Mailing Address - Country:US
Mailing Address - Phone:920-262-6326
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-262-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1800-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant