Provider Demographics
NPI:1699704296
Name:BAUMEISTER, MICHELLE LYNN (OTRL)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:BAUMEISTER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:BRUNNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:3601 30TH AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:262-657-7190
Practice Address - Street 1:25250 75TH ST
Practice Address - Street 2:
Practice Address - City:PADDOCK LAKE
Practice Address - State:WI
Practice Address - Zip Code:53168
Practice Address - Country:US
Practice Address - Phone:262-843-4200
Practice Address - Fax:262-843-4578
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006611225100000X
WI3629026225100000X
WI3629224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40836800Medicaid
WIP00073608OtherRAILROAD MEDICARE NUMBER
WI0604410001OtherDMERC
WIP30936Medicare UPIN
WIP00073608OtherRAILROAD MEDICARE NUMBER
P30936Medicare UPIN