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General NPI Number Information
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NPI Number | 1740496132
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Entity Type | Individual
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Provider Name | SCOTT WADE OLENICZAK
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Gender | Male
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 10/29/2019
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Provider Practice Location Address
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Address Line | 215 N WEBSTER AVE
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City | GREEN BAY
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State | WI
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Zip | 54301-4813
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Country | US
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Telephone | 920-431-5588
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Fax | 920-445-7090
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Provider Business Mailing Address
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Address Line | 3446 EDINBURGH RD
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City | GREEN BAY
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State | WI
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Zip | 54311-7284
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Country | US
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Telephone |
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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 | 3259-026
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License Number State | WI
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