Provider Demographics
NPI:1801208137
Name:JAROSCH, CALLIE J (OT)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:J
Last Name:JAROSCH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:
Other - Last Name:BUDZISZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N112W17975 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-2425
Practice Address - Country:US
Practice Address - Phone:262-532-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-010621225X00000X
WI6064-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100066540Medicaid