Provider Demographics
NPI:1992075758
Name:MARTIN, SUSAN MARIE (COTA)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:MARTIN
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 1:209 JOSEPH CT
Mailing Address - Street 2:#5
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-6415
Mailing Address - Country:US
Mailing Address - Phone:920-725-3606
Mailing Address - Fax:
Practice Address - Street 1:209 JOSEPH CT
Practice Address - Street 2:#5
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-6415
Practice Address - Country:US
Practice Address - Phone:920-725-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4794-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant