Provider Demographics
NPI:1104924042
Name:BOISSONNEAULT, COLLEEN MARGARET (COTA)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARGARET
Last Name:BOISSONNEAULT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARGARET
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:203 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:ROBERTS
Mailing Address - State:WI
Mailing Address - Zip Code:54023-9714
Mailing Address - Country:US
Mailing Address - Phone:715-254-9364
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1919224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40881100Medicaid