Healthcare Provider Details

I. General information

NPI: 1033304076
Provider Name (Legal Business Name): NANCY GENTZ CIPOV OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 N MILWAUKEE ST SUITE 208
MILWAUKEE WI
53202-5308
US

IV. Provider business mailing address

6128 FOUR MILE RD
RACINE WI
53402
US

V. Phone/Fax

Practice location:
  • Phone: 888-389-9030
  • Fax: 888-389-9031
Mailing address:
  • Phone: 262-639-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3793026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: