Healthcare Provider Details

I. General information

NPI: 1104049402
Provider Name (Legal Business Name): MYLINDA ROSE BARISAS-MATULA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

IV. Provider business mailing address

417 SAINT CLAIR AVE
SHEBOYGAN WI
53081-3562
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-5634
  • Fax:
Mailing address:
  • Phone: 920-451-4651
  • Fax: 920-451-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1913-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: