Provider Demographics
NPI:1215050976
Name:MANNEL, LAURA ANN (OT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:MANNEL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S WHITNEY WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4604
Mailing Address - Country:US
Mailing Address - Phone:608-236-4850
Mailing Address - Fax:
Practice Address - Street 1:110 BELMONT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-3129
Practice Address - Country:US
Practice Address - Phone:608-249-7391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2741-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40886400Medicaid