Basic Information
| Provider Information | |||||||||
| NPI: | 1033498001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLESKACHEK | ||||||||
| FirstName: | ASHLEY | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19070 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543079070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1109 W CLAIREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547016105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157174121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5043-026 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100017216 | 05 | WI | MEDICAID |