MEDICARE: DEANDRA KAY WAHL 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	T-02670	KS

General Provider Information

NPI Number	:	1912213679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANDRA KAY WAHL OTR/L

Provider Business Mailing Address
First Line	:	815 N ROTHSAY AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	KS
Zip	:	67467-1637
Country	:	US
Telephone Number	:	785-392-2162
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 N ROTHSAY AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	KS
Zip	:	67467-1637
Country	:	US
Telephone Number	:	785-392-2162
Fax Number	:

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

Provider Enumeration Date	:	08/19/2010
Last Update Date	:	08/19/2010

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