Healthcare Provider Details

I. General information

NPI: 1356272710
Provider Name (Legal Business Name): LORI ANN ANDRUS OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1674 EISENHOWER RD
DE PERE WI
54115-8145
US

IV. Provider business mailing address

1200 REED ST
GREEN BAY WI
54303-3025
US

V. Phone/Fax

Practice location:
  • Phone: 920-337-1393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number366426
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: