Healthcare Provider Details

I. General information

NPI: 1396238366
Provider Name (Legal Business Name): KRISTINE LEE TAYLOR OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S CHET KRAUSE DR
IOLA WI
54945-9300
US

IV. Provider business mailing address

2448 S 102ND ST STE 340
MILWAUKEE WI
53227-2147
US

V. Phone/Fax

Practice location:
  • Phone: 715-445-2412
  • Fax:
Mailing address:
  • Phone: 414-329-2500
  • Fax: 414-329-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2376-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: