Healthcare Provider Details

I. General information

NPI: 1699696005
Provider Name (Legal Business Name): SELENA SOM OTS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14650 GARRETT AVE
APPLE VALLEY MN
55124-7543
US

IV. Provider business mailing address

5085 PONDSEDGE LN
PRIOR LAKE MN
55372-3462
US

V. Phone/Fax

Practice location:
  • Phone: 952-236-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number108147
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: