MEDICARE: AMANDA VICTORIA CLOUD GRAETZER OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	101140	MN

General Provider Information

NPI Number	:	1477630226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA VICTORIA CLOUD GRAETZER OTR/L

Provider Business Mailing Address
First Line	:	7306 24TH AVE N
Second Line	:
City	:	HUGO
State	:	MN
Zip	:	55038-9319
Country	:	US
Telephone Number	:	952-239-3875
Fax Number	:

Provider Business Practice Location Address
First Line	:	6776 LAKE DR # 170
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1156
Country	:	US
Telephone Number	:	651-784-7007
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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