Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | 101179 | MN |
NPI | 1174782957 |
---|---|
Provider Name | Ms. Lisa R White |
First Address | Maple Grove, MN 55311-2677 |
Second Address | Maple Grove, MN 55311-2677 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2008 |
Last Update Date | 08/02/2012 |