Provider Demographics
NPI:1902224330
Name:DERKSEN, MEAGAN MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:MARIE
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MEAGAN
Other - Middle Name:MARIE
Other - Last Name:WICHTERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2131 S BUSINESS DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-5656
Mailing Address - Country:US
Mailing Address - Phone:920-803-1617
Mailing Address - Fax:920-803-1622
Practice Address - Street 1:2131 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-5656
Practice Address - Country:US
Practice Address - Phone:920-803-1617
Practice Address - Fax:920-803-1622
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4965-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4965-27OtherLICENSE