Provider Demographics
NPI:1700979309
Name:BELLENDORF, NANCY ANN (OTR)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
Last Name:BELLENDORF
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:ANN
Other - Last Name:HAAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:135 S GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-8100
Mailing Address - Fax:715-748-8199
Practice Address - Street 1:103 S GIBSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451
Practice Address - Country:US
Practice Address - Phone:715-748-8112
Practice Address - Fax:715-748-8792
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI592-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40624400Medicaid