Provider Demographics
NPI:1255777405
Name:LEISTIKOW, VICKI LYNN (COTA)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LYNN
Last Name:LEISTIKOW
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:BERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-780-0707
Mailing Address - Fax:262-780-1107
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-780-0707
Practice Address - Fax:262-780-1107
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant