Provider Demographics
NPI:1003593112
Name:KRAYENHAGEN, JOHN TRAVIS (OTR)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TRAVIS
Last Name:KRAYENHAGEN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 N WATER ST APT 312
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3623
Mailing Address - Country:US
Mailing Address - Phone:563-650-2889
Mailing Address - Fax:
Practice Address - Street 1:1635 N WATER ST APT 312
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3623
Practice Address - Country:US
Practice Address - Phone:563-650-2889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8316-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist