Provider Demographics
NPI:1770156614
Name:TOLSMA, MARK ROBERT (COTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:TOLSMA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 W HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3857
Mailing Address - Country:US
Mailing Address - Phone:920-266-7437
Mailing Address - Fax:
Practice Address - Street 1:1250 S EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3514
Practice Address - Country:US
Practice Address - Phone:715-526-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
434591OtherNBCOT