Provider Demographics
NPI:1396301933
Name:RICO, RENAE N (OT)
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:N
Last Name:RICO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:N
Other - Last Name:TJELTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1109 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6105
Practice Address - Country:US
Practice Address - Phone:715-717-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6519-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist