Provider Demographics
NPI:1962679712
Name:RODE, DEBORAH ANN (COTA)
Entity Type:Individual
Prefix:MISS
First Name:DEBORAH
Middle Name:ANN
Last Name:RODE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1968
Mailing Address - Country:US
Mailing Address - Phone:920-563-5533
Mailing Address - Fax:920-563-5365
Practice Address - Street 1:430 WILCOX ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1968
Practice Address - Country:US
Practice Address - Phone:920-563-5533
Practice Address - Fax:920-563-5365
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1564-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40886000Medicaid