Provider Demographics
NPI:1457772907
Name:WISE, KERRIE ANN (COTA)
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:ANN
Last Name:WISE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10637 SE 238TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3571
Mailing Address - Country:US
Mailing Address - Phone:206-412-5722
Mailing Address - Fax:
Practice Address - Street 1:10637 SE 238TH ST APT B
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-3571
Practice Address - Country:US
Practice Address - Phone:206-412-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60315592224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant