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NPI Code Detail

MEDICARE: DR. KARISSA JOY WENNSTROM OTD, OTR

MEDICARE: DR. KARISSA JOY WENNSTROM OTD, OTR
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
1225X00000XOccupational Therapist
2225XP0200XPediatric Occupational Therapist

General Provider Information

NPI Number : 1306652250
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KARISSA JOY WENNSTROM OTD, OTR
Provider Business Mailing Address
First Line : 1010 DEEP LAKE RD
Second Line :
City : ANTIOCH
State : IL
Zip : 60002-7271
Country : US
Telephone Number : 847-417-1311
Fax Number :
Provider Business Practice Location Address
First Line : 2833 N CLYBOURN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60618-8470
Country : US
Telephone Number : 847-604-0027
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/05/2024
Last Update Date : 12/05/2024

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