Provider Demographics
NPI:1851573596
Name:WEIDNER-RUEDIGER, MARY ELLEN (OTR)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:WEIDNER-RUEDIGER
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:W5004 BEECHNUT AVENUE
Mailing Address - Street 2:
Mailing Address - City:REDGRANITE
Mailing Address - State:WI
Mailing Address - Zip Code:54970-6904
Mailing Address - Country:US
Mailing Address - Phone:920-470-8442
Mailing Address - Fax:
Practice Address - Street 1:W5004 BEECHNUT AVENUE
Practice Address - Street 2:
Practice Address - City:REDGRANITE
Practice Address - State:WI
Practice Address - Zip Code:54970-6904
Practice Address - Country:US
Practice Address - Phone:920-470-8442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1547-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40577400Medicaid