Provider Demographics
NPI:1316259898
Name:DETRICK, KAREN A (COTA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:DETRICK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 PILGRAM WAY
Mailing Address - Street 2:WOODSIDE SENIOR COMMUNITIES
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304
Mailing Address - Country:US
Mailing Address - Phone:920-405-3522
Mailing Address - Fax:920-405-3523
Practice Address - Street 1:1040 PILGRAM WAY
Practice Address - Street 2:WOODSIDE SENIOR COMMUNITIES
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-405-3522
Practice Address - Fax:920-405-3523
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI883-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant