Healthcare Provider Details

I. General information

NPI: 1588851075
Provider Name (Legal Business Name): KARISSA ANNE YOURA OTR, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 NEW PINERY RD STE 103
PORTAGE WI
53901-9257
US

IV. Provider business mailing address

2817 NEW PINERY RD STE 103
PORTAGE WI
53901-9257
US

V. Phone/Fax

Practice location:
  • Phone: 608-745-6290
  • Fax: 608-745-6250
Mailing address:
  • Phone: 608-745-6290
  • Fax: 608-745-6250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3886-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: