Provider Demographics
NPI:1871701680
Name:WISER, SUE RANETTE (COTA)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:RANETTE
Last Name:WISER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 OAK HILL DR
Mailing Address - Street 2:
Mailing Address - City:STRAFFORD
Mailing Address - State:MO
Mailing Address - Zip Code:65757-7864
Mailing Address - Country:US
Mailing Address - Phone:417-859-6327
Mailing Address - Fax:
Practice Address - Street 1:331 HOSPITAL DR
Practice Address - Street 2:SUITE D
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9217
Practice Address - Country:US
Practice Address - Phone:417-533-6315
Practice Address - Fax:417-533-6320
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001236224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant