Basic Information
| Provider Information | |||||||||
| NPI: | 1164548731 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KLAK | ||||||||
| FirstName: | CAROL | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3121 CRUSADE LN | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543134303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1142 ORLANDO DR | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541159484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203390700 | ||||||||
| FaxNumber: | 9203300278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1491-026 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40567000 | 05 | WI | MEDICAID |