Provider Demographics
NPI:1316475650
Name:RENNICKE, KASEY CATHERINE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:KASEY
Middle Name:CATHERINE
Last Name:RENNICKE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W ELDRED ST APT 16
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2687
Mailing Address - Country:US
Mailing Address - Phone:920-840-2910
Mailing Address - Fax:
Practice Address - Street 1:2400 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6738
Practice Address - Country:US
Practice Address - Phone:715-848-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4971-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant