Provider Demographics
NPI:1043781594
Name:ANDERSEN, SARA (OT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 E SAVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-4022
Mailing Address - Country:US
Mailing Address - Phone:414-477-6263
Mailing Address - Fax:
Practice Address - Street 1:13203 GLOBE DR STE 111
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1616
Practice Address - Country:US
Practice Address - Phone:262-287-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6436-26225XP0200X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043781594Medicaid