Basic Information
| Provider Information | |||||||||
| NPI: | 1316259898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETRICK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 PILGRAM WAY | ||||||||
| Address2: | WOODSIDE SENIOR COMMUNITIES | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204053522 | ||||||||
| FaxNumber: | 9204053523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 PILGRAM WAY | ||||||||
| Address2: | WOODSIDE SENIOR COMMUNITIES | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204053522 | ||||||||
| FaxNumber: | 9204053523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2010 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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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 | 224Z00000X | 883-27 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.