Provider Demographics
NPI:1295967743
Name:LEARY, REGINA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:LEARY
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 1:4435 BROOKSIDE CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:ABRAMS
Mailing Address - State:WI
Mailing Address - Zip Code:54101
Mailing Address - Country:US
Mailing Address - Phone:920-826-2306
Mailing Address - Fax:
Practice Address - Street 1:261 FRENCH STREET
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157
Practice Address - Country:US
Practice Address - Phone:715-582-2200
Practice Address - Fax:715-582-2222
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI741-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40714600Medicaid