Provider Demographics
NPI:1073780607
Name:CHRISTENSEN, CAROL JEAN (OTR)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:CHRISTENSEN
Suffix:
Gender:F
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:N1411 SAINT JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-9656
Mailing Address - Country:US
Mailing Address - Phone:920-563-4650
Mailing Address - Fax:
Practice Address - Street 1:611 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI724-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40579100Medicaid