Provider Demographics
NPI:1700520590
Name:WILDER, KARLEE ROSE (COTA)
Entity Type:Individual
Prefix:
First Name:KARLEE
Middle Name:ROSE
Last Name:WILDER
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 1:4560 SE INTERNATIONAL WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:971-206-5202
Mailing Address - Fax:
Practice Address - Street 1:10901 176TH CIR NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-7218
Practice Address - Country:US
Practice Address - Phone:426-556-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC61232941224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOC61232941Medicaid