Provider Demographics
NPI:1821331570
Name:WAKEFIELD, CORTNEY KIM (OTR/L)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:KIM
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CLIFF RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7736
Mailing Address - Country:US
Mailing Address - Phone:507-219-0504
Mailing Address - Fax:
Practice Address - Street 1:13 CLIFF RIDGE CT
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7736
Practice Address - Country:US
Practice Address - Phone:507-219-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104445225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
306911OtherNBCOT CERTIFICATION
MN104445OtherMN LICENSE