Provider Demographics
NPI:1700351368
Name:VANG, MAI DER (OTR)
Entity Type:Individual
Prefix:
First Name:MAI DER
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 MEMORIAL DRIEVE
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241
Mailing Address - Country:US
Mailing Address - Phone:920-793-7579
Mailing Address - Fax:
Practice Address - Street 1:225 CHURCH ST
Practice Address - Street 2:
Practice Address - City:KOHLER
Practice Address - State:WI
Practice Address - Zip Code:53044-1502
Practice Address - Country:US
Practice Address - Phone:920-889-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6374-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist