Provider Demographics
NPI:1205131075
Name:EKSTROM, SARAH GWYN (OTR)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:GWYN
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 N 77TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3914
Mailing Address - Country:US
Mailing Address - Phone:414-581-8210
Mailing Address - Fax:
Practice Address - Street 1:9632 W APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-3305
Practice Address - Country:US
Practice Address - Phone:414-461-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4760-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist