Healthcare Provider Details

I. General information

NPI: 1528159134
Provider Name (Legal Business Name): ERIN TASHA BEUSSMAN OTRIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W 94TH STREET
BLOOMINGTON MN
55420
US

IV. Provider business mailing address

1105 DUCKWOOD TRAILS #310
EAGAN MN
55123
US

V. Phone/Fax

Practice location:
  • Phone: 952-885-0418
  • Fax: 952-885-0173
Mailing address:
  • Phone: 651-454-6942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103249
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: