Provider Demographics
NPI:1174703987
Name:WILD, KAREN ROSE (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:KAREN
Middle Name:ROSE
Last Name:WILD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6839 S JUNETT ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6050
Mailing Address - Country:US
Mailing Address - Phone:253-473-5911
Mailing Address - Fax:
Practice Address - Street 1:514 S 13TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1908
Practice Address - Country:US
Practice Address - Phone:253-396-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health