Provider Demographics
NPI:1386946135
Name:RENARD, SUSAN LAVERNE (COTA)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LAVERNE
Last Name:RENARD
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 1:1760 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3216
Mailing Address - Country:US
Mailing Address - Phone:920-499-5191
Mailing Address - Fax:920-499-8959
Practice Address - Street 1:1760 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:920-499-5191
Practice Address - Fax:920-499-8959
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI392-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant