Provider Demographics
NPI:1215669155
Name:WANDERSEE, MIKAYLA (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:WANDERSEE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 W WOODS DR APT 801
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2087
Mailing Address - Country:US
Mailing Address - Phone:952-715-1066
Mailing Address - Fax:
Practice Address - Street 1:2013 MIDWEST RD
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1312
Practice Address - Country:US
Practice Address - Phone:630-495-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02121996Medicaid