Healthcare Provider Details

I. General information

NPI: 1891419156
Provider Name (Legal Business Name): KATHRYN LANDGRAF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD
WAUWATOSA WI
53226-3462
US

IV. Provider business mailing address

1155 N MAYFAIR RD
WAUWATOSA WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-4263
  • Fax: 414-955-6286
Mailing address:
  • Phone: 414-955-4263
  • Fax: 414-955-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8075-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: