Basic Information
| Provider Information | |||||||||
| NPI: | 1881869949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PFANKUCH | ||||||||
| FirstName: | SHARI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUCKSCHEN | ||||||||
| OtherFirstName: | SHARI | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | OCCUPATIONAL THER | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | W6116 PINE LANE | ||||||||
| Address2: | SHARI PFANKUCH | ||||||||
| City: | CRIVITZ | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7159274010 | ||||||||
| FaxNumber: | 7158547501 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E HIGHLAND DRIVE | ||||||||
| Address2: | SHARPE CARE | ||||||||
| City: | OCONTO FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208483272 | ||||||||
| FaxNumber: | 9208487833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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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 | 225X00000X | 654026 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40686900 | 05 | WI | MEDICAID |