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General NPI Number Information
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NPI Number | 1730885047
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Entity Type | Individual
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Provider Name | MERCEDES LYNN ANTOLAK OTR/L
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Gender | Female
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Dates
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Enumeration Date | 02/07/2023
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Last Update Date | 08/25/2023
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Provider Practice Location Address
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Address Line | 310 WEST MAIN STREET
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City | SPARTA
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State | WI
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Zip | 54656-2170
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Country | US
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Telephone | 608-758-0940
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Fax |
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Provider Business Mailing Address
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Address Line | 200 1ST STREET SW
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City | ROCHESTER
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State | MN
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Zip | 55905-4054
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Country | US
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Telephone | 507-284-2511
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 5989
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 8182-26
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License Number State | WI
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