MEDICARE: KRISTIANA R MAGGARD OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	4673	WI

General Provider Information

NPI Number	:	1184254336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIANA R MAGGARD OT

Provider Business Mailing Address
First Line	:	10180 WASHINGTON AVE # 107
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53177-1604
Country	:	US
Telephone Number	:	262-687-7500
Fax Number	:	262-687-7501

Provider Business Practice Location Address
First Line	:	10180 WASHINGTON AVE # 107
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53177-1604
Country	:	US
Telephone Number	:	262-687-7500
Fax Number	:	262-687-7501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	01/16/2020

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