Provider Demographics
NPI:1720308026
Name:ANNEN, MARY T (OTR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:ANNEN
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 1:1040 PILGRIM WAY
Mailing Address - Street 2:
Mailing Address - City:ASHWAUBENON
Mailing Address - State:WI
Mailing Address - Zip Code:54304
Mailing Address - Country:US
Mailing Address - Phone:920-405-3522
Mailing Address - Fax:
Practice Address - Street 1:1040 PILGRIM WAY
Practice Address - Street 2:WOODSIDE LUTHERAN HOME
Practice Address - City:ASHWAUBENON
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-405-3522
Practice Address - Fax:920-405-3523
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI713-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist