Provider Demographics
NPI:1770783755
Name:GILDENZOPH, ELISABETH ANNE (COTA)
Entity type:Individual
Prefix:MISS
First Name:ELISABETH
Middle Name:ANNE
Last Name:GILDENZOPH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 WISCONSIN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:PORT EDWARDS
Mailing Address - State:WI
Mailing Address - Zip Code:54469-1043
Mailing Address - Country:US
Mailing Address - Phone:715-887-2005
Mailing Address - Fax:
Practice Address - Street 1:611 SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1832
Practice Address - Country:US
Practice Address - Phone:715-387-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1904-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1904-027OtherSTATE CERTIFICATION
WI1071855OtherNBCOT CERTIFICATION