Provider Demographics
NPI:1740327618
Name:GOLDBACH, WENDY P (OTD MED OTR CHT)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:P
Last Name:GOLDBACH
Suffix:
Gender:F
Credentials:OTD MED OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 BIBLE CAMP RD
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501
Mailing Address - Country:US
Mailing Address - Phone:715-490-2954
Mailing Address - Fax:715-282-7161
Practice Address - Street 1:12800 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2418
Practice Address - Country:US
Practice Address - Phone:262-243-4261
Practice Address - Fax:262-243-4261
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1092026225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780663013OtherNPI
WI40547700Medicaid
WI1092-26OtherWISCONSIN STATE LICENSE
WI000086622Medicare ID - Type Unspecified
R95830Medicare UPIN