Provider Demographics
NPI:1316264260
Name:SMITH, SUSAN LYNN (COTA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 N MILWAUKEE ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5885
Mailing Address - Country:US
Mailing Address - Phone:414-264-5690
Mailing Address - Fax:
Practice Address - Street 1:316 N MILWAUKEE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5885
Practice Address - Country:US
Practice Address - Phone:414-264-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1051-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant