Basic Information
Provider Information | |||||||||
NPI: | 1093470833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOLEY | ||||||||
FirstName: | DAWN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | COTA,L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5150 N PORT WASHINGTON RD | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | WI | ||||||||
PostalCode: | 532175474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149625250 | ||||||||
FaxNumber: | 4149625251 | ||||||||
Practice Location | |||||||||
Address1: | 911 3RD ST W | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 548061311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156828172 | ||||||||
FaxNumber: | 7156826662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2021 | ||||||||
LastUpdateDate: | 11/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 5817-27 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
No ID Information.