Individual
KENNEDY LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
X
Contact information
Practice address
13250 WASHINGTON AVE, MOUNT PLEASANT, WI 53177-1516
(262) 799-8330
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
9045
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100390531
—
WI
Enumeration date
12/01/2025
Last updated
12/23/2025
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