Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 103691 | MN |
NPI | 1003066614 |
---|---|
Provider Name | Carissa Kusilek |
First Address | Stillwater, MN 55082-6070 |
Second Address | Stillwater, MN 55082-6070 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2008 |
Last Update Date | 30/06/2009 |