Provider Demographics
NPI:1811033749
Name:MEYER, SUSAN M (OTR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MEYER
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 1:111 W WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1616
Mailing Address - Country:US
Mailing Address - Phone:920-954-8319
Mailing Address - Fax:
Practice Address - Street 1:3305 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9001
Practice Address - Country:US
Practice Address - Phone:920-735-9234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4160225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40891000Medicaid