Provider Demographics
NPI:1982003331
Name:PHELPS, TERRA (OTR)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1840
Mailing Address - Country:US
Mailing Address - Phone:319-930-1888
Mailing Address - Fax:
Practice Address - Street 1:3821 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3600
Practice Address - Country:US
Practice Address - Phone:920-208-9648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5534-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist