Healthcare Provider Details

I. General information

NPI: 1750145595
Provider Name (Legal Business Name): ANDREA NYBERG MA, OTR/L, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 18TH AVE E
ALEXANDRIA MN
56308-2511
US

IV. Provider business mailing address

4355 DONWAY DR NE
ALEXANDRIA MN
56308-5095
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-6079
  • Fax:
Mailing address:
  • Phone: 320-808-6644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103185
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: