Healthcare Provider Details

I. General information

NPI: 1730451196
Provider Name (Legal Business Name): JOANNE MARIE OWEN OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOANNE MARIE BOHL OTA

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2961 SAINT ANTHONY DR
GREEN BAY WI
54311-5860
US

IV. Provider business mailing address

2961 SAINT ANTHONY DR
GREEN BAY WI
54311-5860
US

V. Phone/Fax

Practice location:
  • Phone: 920-468-0861
  • Fax: 920-569-1566
Mailing address:
  • Phone: 920-468-0861
  • Fax: 920-569-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number204527
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: