Provider Demographics
NPI:1104151406
Name:WAHLGREN, KAREN BETH (OTR, MS)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:BETH
Last Name:WAHLGREN
Suffix:
Gender:F
Credentials:OTR, MS
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:BETH
Other - Last Name:LICSKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1957
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:
Practice Address - Street 1:3601 30TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1695
Practice Address - Country:US
Practice Address - Phone:262-657-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2237026225X00000X
IL056008379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist