Healthcare Provider Details

I. General information

NPI: 1376743385
Provider Name (Legal Business Name): MARCIE MARIE WENZEL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CLARK ST
LODI WI
53555-1010
US

IV. Provider business mailing address

W10633 CASCADE MOUNTAIN RD
PORTAGE WI
53901-9631
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-3241
  • Fax:
Mailing address:
  • Phone: 608-742-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1349027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: