Provider Demographics
NPI:1780663013
Name:COURTNEY STREET REHAB CLINIC LTD
Entity type:Organization
Organization Name:COURTNEY STREET REHAB CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOLDBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MED, OTR, CHT
Authorized Official - Phone:715-369-7474
Mailing Address - Street 1:203 SCHIEK PLAZA
Mailing Address - Street 2:PO BOX 1161
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501
Mailing Address - Country:US
Mailing Address - Phone:715-369-7474
Mailing Address - Fax:715-369-7475
Practice Address - Street 1:203 SCHIEK PLAZA
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:715-369-7474
Practice Address - Fax:715-369-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40547700Medicaid
R95830Medicare UPIN
WI40547700Medicaid