Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 4850-27 | WI |
NPI | 1013252295 |
---|---|
Provider Name | Emily A Bourg |
First Address | Marshfield, WI 54449-5023 |
Second Address | Marshfield, WI 54449-4030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2012 |
Last Update Date | 29/11/2012 |