Provider Demographics
NPI:1871801621
Name:MEYER, CHAD (COTA)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:MEYER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-1342
Mailing Address - Country:US
Mailing Address - Phone:920-810-2825
Mailing Address - Fax:
Practice Address - Street 1:500 GRANT AVE.
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963
Practice Address - Country:US
Practice Address - Phone:920-810-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI474527224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871801621Medicaid