Healthcare Provider Details

I. General information

NPI: 1104191824
Provider Name (Legal Business Name): DEANNA P DORAISWAMY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2961 SAINT ANTHONY DR
GREEN BAY WI
54311
US

IV. Provider business mailing address

2060 E PLANK RD UNIT 3
APPLETON WI
54915-7045
US

V. Phone/Fax

Practice location:
  • Phone: 920-468-0861
  • Fax:
Mailing address:
  • Phone: 920-655-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4982-026
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119005787
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: