Provider Demographics
NPI:1922145903
Name:DEDITZ, REBECCA JANE (OTR)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:DEDITZ
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 1:1234 SHARON LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-8935
Mailing Address - Country:US
Mailing Address - Phone:715-479-6971
Mailing Address - Fax:
Practice Address - Street 1:2383 STATE HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:PHELPS
Practice Address - State:WI
Practice Address - Zip Code:54554-9472
Practice Address - Country:US
Practice Address - Phone:715-545-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1513-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40712700Medicaid