Provider Demographics
NPI:1457565228
Name:WILSON, KRISTINE MARIE (OT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:VUKELICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:6458 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3245
Mailing Address - Country:US
Mailing Address - Phone:612-767-7222
Mailing Address - Fax:
Practice Address - Street 1:6458 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3245
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201405224Z00000X
MN104701225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN201405OtherMN LICENSURE
MN104701OtherOT LICENSURE
MN201405OtherMN LICENSURE