Healthcare Provider Details

I. General information

NPI: 1578830329
Provider Name (Legal Business Name): DIANE C ROTH OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

IV. Provider business mailing address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

V. Phone/Fax

Practice location:
  • Phone: 218-927-2121
  • Fax:
Mailing address:
  • Phone: 218-927-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number101257
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: