Provider Demographics
NPI:1669935359
Name:BALCERAK, LAURA A (COTA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:BALCERAK
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:W156S7464 MARTIN CT
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8395
Mailing Address - Country:US
Mailing Address - Phone:414-531-3598
Mailing Address - Fax:
Practice Address - Street 1:W156S7464 MARTIN CT
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8395
Practice Address - Country:US
Practice Address - Phone:414-531-3598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI651-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant