Provider Demographics
NPI:1245458140
Name:DEMICCO, TAMMIE EILEEN (COTA)
Entity type:Individual
Prefix:MISS
First Name:TAMMIE
Middle Name:EILEEN
Last Name:DEMICCO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14 WILDWOOD CT UNIT D
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53191-9647
Mailing Address - Country:US
Mailing Address - Phone:262-245-0219
Mailing Address - Fax:262-728-7129
Practice Address - Street 1:1922 COUNTY RD. NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121
Practice Address - Country:US
Practice Address - Phone:262-741-3630
Practice Address - Fax:262-743-1855
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1812-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40850800Medicaid