Provider Demographics
NPI:1386709442
Name:REICHENBERGER, SUSAN ELAINE (OTR)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:REICHENBERGER
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:N26W26210 QUAIL HOLLOW RD
Mailing Address - Street 2:#1
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4547
Mailing Address - Country:US
Mailing Address - Phone:262-695-0397
Mailing Address - Fax:
Practice Address - Street 1:W231S7680 BIG BEND DR
Practice Address - Street 2:
Practice Address - City:BIG BEND
Practice Address - State:WI
Practice Address - Zip Code:53103-9686
Practice Address - Country:US
Practice Address - Phone:262-662-9760
Practice Address - Fax:262-662-9761
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4158026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4158026OtherSTATE OF WI OT LICENSE #
WI40876600Medicaid