Healthcare Provider Details

I. General information

NPI: 1619550449
Provider Name (Legal Business Name): CHANEL BECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W 9TH AVE
OSHKOSH WI
54904-7247
US

IV. Provider business mailing address

N7360 COUNTY ROAD C
ELDORADO WI
54932-9601
US

V. Phone/Fax

Practice location:
  • Phone: 920-223-2000
  • Fax:
Mailing address:
  • Phone: 920-979-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5766-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: