Provider Demographics
NPI:1659118768
Name:WIESBROOK, LAUREN (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WIESBROOK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 N MURRAY AVE # C
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3918
Mailing Address - Country:US
Mailing Address - Phone:630-270-7537
Mailing Address - Fax:
Practice Address - Street 1:5930 CORNERSTONE CT W STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3772
Practice Address - Country:US
Practice Address - Phone:866-687-7390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8295-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist