Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 5652 | WI |
NPI | 1003569815 |
---|---|
Provider Name | Tyler Christian Mogensen |
First Address | Appleton, WI 54911-1325 |
Second Address | Appleton, WI 54911-1325 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2022 |
Last Update Date | 01/02/2022 |