Provider Demographics
NPI:1952506933
Name:WOLF, LAURA JANE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JANE
Last Name:WOLF
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JANE
Other - Last Name:MUGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6931 LAKEVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-9015
Mailing Address - Country:US
Mailing Address - Phone:715-349-2025
Mailing Address - Fax:715-468-4232
Practice Address - Street 1:802 E COUNTY HWY B
Practice Address - Street 2:TERRACEVIEW LIVING CENTER
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0609
Practice Address - Country:US
Practice Address - Phone:715-468-7292
Practice Address - Fax:715-468-4232
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1845027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40887600Medicaid