Provider Demographics
NPI:1982877346
Name:WACHOWIAK, LISA ANN (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WACHOWIAK
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 1:3129 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3062
Mailing Address - Country:US
Mailing Address - Phone:920-458-1155
Mailing Address - Fax:
Practice Address - Street 1:3129 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3062
Practice Address - Country:US
Practice Address - Phone:920-458-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI387-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant