Provider Demographics
NPI:1023500741
Name:FOSSUM, EILEEN M (COTA)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:M
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:N1530 BREIDEL COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2168
Mailing Address - Country:US
Mailing Address - Phone:608-397-8368
Mailing Address - Fax:
Practice Address - Street 1:614 S ROCK AVE
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1936
Practice Address - Country:US
Practice Address - Phone:608-637-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4813-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant