Healthcare Provider Details

I. General information

NPI: 1376574756
Provider Name (Legal Business Name): WILLIAM ROBERT BAHNFLETH JR. M.S. OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 YORK ST
MANITOWOC WI
54220-6845
US

IV. Provider business mailing address

2300 WESTERN AVE PO BOX 2170
MANITOWOC WI
54221-2170
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-6750
  • Fax: 920-682-1981
Mailing address:
  • Phone: 920-320-8667
  • Fax: 920-320-8616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number293026
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier40524700
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer
# 2
Identifier717436
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerT19 MANAGED HEALTH SERVIC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: