Individual
JUSTINE ANN BANTLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
701 WILLOW ST, PESHTIGO, WI 54157
(715) 582-3962
(715) 582-9115
Mailing address
N2969 GREEN GABLE ROAD, MARINETTE, WI 54143
(715) 735-8970
(715) 582-9115
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
1992-027
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
41073500
—
WI
Enumeration date
11/26/2008
Last updated
11/26/2008
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