Provider Demographics
NPI:1861666588
Name:VANCLEVE, ANGELA IRENE (COTA)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:IRENE
Last Name:VANCLEVE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:IRENE
Other - Last Name:KANZENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:7517 W COLD SPRING RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-2814
Mailing Address - Country:US
Mailing Address - Phone:414-327-6603
Mailing Address - Fax:414-327-5411
Practice Address - Street 1:100 E. HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154
Practice Address - Country:US
Practice Address - Phone:920-848-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2024-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11014100Medicaid
WI390848401050OtherBLUE CROSS
WI11014110Medicaid
WI521310Medicare Oscar/Certification
WI390848401050OtherBLUE CROSS
WI11014110Medicaid