Provider Demographics
NPI:1194087734
Name:DEDERICH, EMMA JEAN (OTR)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:JEAN
Last Name:DEDERICH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1503
Mailing Address - Country:US
Mailing Address - Phone:608-356-1400
Mailing Address - Fax:
Practice Address - Street 1:1414 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1503
Practice Address - Country:US
Practice Address - Phone:608-356-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5172-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist