Provider Demographics
NPI:1710593058
Name:WROLSTAD, MIKAYLA RENAE (OT)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:RENAE
Last Name:WROLSTAD
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 1:1620 S PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2487
Mailing Address - Country:US
Mailing Address - Phone:509-766-2670
Mailing Address - Fax:509-766-2689
Practice Address - Street 1:1620 S PIONEER WAY
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2487
Practice Address - Country:US
Practice Address - Phone:509-766-2670
Practice Address - Fax:509-766-2689
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61052997225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist