Healthcare Provider Details

I. General information

NPI: 1861437808
Provider Name (Legal Business Name): ALEXANDRA MARTHA CARLSON MS, OTR, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD
MEQUON WI
53097-2416
US

IV. Provider business mailing address

12920 W GRAHAM ST
NEW BERLIN WI
53151-2639
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7444
  • Fax: 262-243-7486
Mailing address:
  • Phone: 262-796-1373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1135026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: