Basic Information
Provider Information | |||||||||
NPI: | 1558619163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LATHROP | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | COTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 704 LEXINGTON BLVD. | ||||||||
Address2: |   | ||||||||
City: | FORT ATKINSON | ||||||||
State: | WI | ||||||||
PostalCode: | 535389322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9206507728 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1020 HILL ST | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530983016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9202064935 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2012 | ||||||||
LastUpdateDate: | 02/26/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 4923-27 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
No ID Information.