Healthcare Provider Details

I. General information

NPI: 1275107971
Provider Name (Legal Business Name): LIVING WELL OCCUPATIONAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 ELM GROVE RD STE 28
ELM GROVE WI
53122-2531
US

IV. Provider business mailing address

910 ELM GROVE RD STE 28
ELM GROVE WI
53122-2531
US

V. Phone/Fax

Practice location:
  • Phone: 262-737-2377
  • Fax:
Mailing address:
  • Phone: 262-737-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE BOYINGTON
Title or Position: MANAGER
Credential:
Phone: 262-226-6265