Basic Information
| Provider Information | |||||||||
| NPI: | 1700520590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | KARLEE | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065202 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10901 176TH CIR NE | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980527218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4265568100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2022 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OC61232941 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | OC61232941 | 05 | WA | MEDICAID |