Provider Demographics
NPI:1588851075
Name:YOURA, KARISSA ANNE (OTR, CLT)
Entity Type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:ANNE
Last Name:YOURA
Suffix:
Gender:F
Credentials:OTR, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 NEW PINERY RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9257
Mailing Address - Country:US
Mailing Address - Phone:608-745-6290
Mailing Address - Fax:608-745-6250
Practice Address - Street 1:2817 NEW PINERY RD STE 103
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-6290
Practice Address - Fax:608-745-6250
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3886-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3886-026OtherOT LICENSE
WI40894100Medicaid