Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 103690 | MN |
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 103690 | MN |
NPI | 1023311412 |
---|---|
Provider Name | Tera White |
First Address | Fridley, MN 55432-3702 |
Second Address | Fridley, MN 55432-3702 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/12/2010 |
Last Update Date | 07/12/2010 |