Basic Information
| Provider Information | |||||||||
| NPI: | 1326215732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | S4555 HWY CH | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539599511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085247511 | ||||||||
| FaxNumber: | 6085247599 | ||||||||
| Practice Location | |||||||||
| Address1: | S4555 HWY CH | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539599511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085247511 | ||||||||
| FaxNumber: | 6085247599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 241027 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2410Z7 | 01 | WI | STATE OF WIS DEPT OF REGULATION AND LICENSING | OTHER | 4066Z700 | 05 | WI | MEDICAID | AA532887 | 01 | NATIONAL BOARD FOR CERTIFICATION IN OCUPATIONAL THERAPY INC | OTHER |