Healthcare Provider Details

I. General information

NPI: 1003029406
Provider Name (Legal Business Name): MANDI ANN HERWIG C.O.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

323 WEST MONROE STREET
WYOCENA WI
53969
US

IV. Provider business mailing address

N7584 STONEHAVEN DR
PORTAGE WI
53901-9149
US

V. Phone/Fax

Practice location:
  • Phone: 608-429-2181
  • Fax:
Mailing address:
  • Phone: 608-742-3067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1361-027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: