Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 056.011329 | IL |
Y | 225XG0600X | Occupational Therapist - Gerontology | 5819-26 | WI |
NPI | 1558729269 |
---|---|
Provider Name | Carla Correa |
First Address | Kenosha, WI 53142-3109 |
Second Address | Mount Pleasant, WI 53406-3777 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2016 |
Last Update Date | 09/02/2016 |