Provider Demographics
NPI:1194990242
Name:EIDEN, KATHERINE LEE (OTR)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LEE
Last Name:EIDEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4904
Mailing Address - Country:US
Mailing Address - Phone:715-298-2060
Mailing Address - Fax:
Practice Address - Street 1:3312 TERRACE CT
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4904
Practice Address - Country:US
Practice Address - Phone:715-298-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2345-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40768800Medicaid
WI2345-26OtherLICENSE NUMBER