MEDICARE: MRS. KAITLYN WISE OTR/L

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	16165	FL

General Provider Information

NPI Number	:	1164832895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAITLYN WISE OTR/L

Provider Business Mailing Address
First Line	:	2517 EASTLAKE AVE E. #102
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102
Country	:	US
Telephone Number	:	206-322-5433
Fax Number	:	954-514-1126

Provider Business Practice Location Address
First Line	:	2517 EASTLAKE AVE E. #102
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102
Country	:	US
Telephone Number	:	206-322-5433
Fax Number	:	954-514-1126

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

Provider Enumeration Date	:	05/02/2014
Last Update Date	:	01/23/2017

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