Basic Information
| Provider Information | |||||||||
| NPI: | 1972601524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 WEST AVE S | ||||||||
| Address2: | PHYSICIAN SERVICES | ||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087914156 | ||||||||
| FaxNumber: | 6087919898 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 WEST AVENUE SOUTH | ||||||||
| Address2: | |||||||||
| City: | LACROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 56401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087919768 | ||||||||
| FaxNumber: | 6087917124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1789 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40753900 | 05 | WI | MEDICAID |