Healthcare Provider Details

I. General information

NPI: 1992806558
Provider Name (Legal Business Name): HEIDI L BRUENE MOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 W MEQUON RD
MEQUON WI
53092-3268
US

IV. Provider business mailing address

3236 TWIN CREEKS RD
JACKSON WI
53037-8912
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-8030
  • Fax:
Mailing address:
  • Phone: 262-420-8282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3908-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: