Provider Demographics
NPI:1063922409
Name:HALVORSON, KARISSA (COTA)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KARISSA
Other - Middle Name:KAY
Other - Last Name:ROHDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:113 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871
Mailing Address - Country:US
Mailing Address - Phone:715-468-7833
Mailing Address - Fax:715-468-7839
Practice Address - Street 1:113 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871
Practice Address - Country:US
Practice Address - Phone:715-468-7833
Practice Address - Fax:715-468-7839
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5405-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant