Provider Demographics
NPI:1578606208
Name:MATTHIAS, CHRISTINE MARY (COTA)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARY
Last Name:MATTHIAS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:MARY
Other - Last Name:WELBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N8015 LAKE BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9613
Mailing Address - Country:US
Mailing Address - Phone:920-989-5074
Mailing Address - Fax:920-759-1937
Practice Address - Street 1:N8015 LAKE BREEZE DR
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:WI
Practice Address - Zip Code:54169-9613
Practice Address - Country:US
Practice Address - Phone:920-989-5074
Practice Address - Fax:920-759-1937
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
108-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI108-027OtherSTATE LICENSURE
WI086293OtherNBCOT
WI40900700Medicaid