Provider Demographics
NPI:1326215732
Name:HUBER, MARY JO
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:HUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S4555 HWY CH
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-9511
Mailing Address - Country:US
Mailing Address - Phone:608-524-7511
Mailing Address - Fax:608-524-7599
Practice Address - Street 1:S4555 HWY CH
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-9511
Practice Address - Country:US
Practice Address - Phone:608-524-7511
Practice Address - Fax:608-524-7599
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI241027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2410Z7OtherSTATE OF WIS DEPT OF REGULATION AND LICENSING
WI4066Z700Medicaid
AA532887OtherNATIONAL BOARD FOR CERTIFICATION IN OCUPATIONAL THERAPY INC