Provider Demographics
NPI:1336659945
Name:MATERNOSKI, KATELYN ROSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:MATERNOSKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ROSE
Other - Last Name:MUTSCHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1919 N SUMMIT AVE UNIT 5B
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1380
Mailing Address - Country:US
Mailing Address - Phone:612-437-8717
Mailing Address - Fax:
Practice Address - Street 1:2301 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-291-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6147-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist