Provider Demographics
NPI:1669798922
Name:WIENER, KRISTA LYN (COTA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYN
Last Name:WIENER
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 1:250 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:PARK FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54552-1431
Mailing Address - Country:US
Mailing Address - Phone:715-762-2449
Mailing Address - Fax:715-762-3321
Practice Address - Street 1:250 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1431
Practice Address - Country:US
Practice Address - Phone:715-762-2449
Practice Address - Fax:715-762-3321
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4600-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant