Provider Demographics
NPI:1063941169
Name:WAHLGREN, SAMANTHA LEIGH (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:WAHLGREN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 TOMAHAWK DR
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:53181-9808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3516 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5732
Practice Address - Country:US
Practice Address - Phone:262-661-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010763225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist