Basic Information
Provider Information | |||||||||
NPI: | 1346621018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WASKOSKY | ||||||||
FirstName: | ALLYSON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSOT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCCORISON | ||||||||
OtherFirstName: | ALLYSON | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSOT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2195 N SUMMIT VILLAGE WAY | ||||||||
Address2: |   | ||||||||
City: | OCONOMOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 530668675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2625674662 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2195 N SUMMIT VILLAGE WAY | ||||||||
Address2: |   | ||||||||
City: | OCONOMOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 53066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2625674662 | ||||||||
FaxNumber: | 4143717598 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2015 | ||||||||
LastUpdateDate: | 08/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5564-26 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 100061618 | 05 | WI |   | MEDICAID |