Provider Demographics
NPI:1740496132
Name:OLENICZAK, SCOTT WADE
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WADE
Last Name:OLENICZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3446 EDINBURGH RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7284
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 N WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4813
Practice Address - Country:US
Practice Address - Phone:920-431-5588
Practice Address - Fax:920-445-7090
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3259-026225X00000X, 225XE1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40814600Medicaid