Healthcare Provider Details

I. General information

NPI: 1790900520
Provider Name (Legal Business Name): ANGELA JF ELLINGSON MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA JEAN FENEIS

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WEST 94TH STREET
BLOOMINGTON MN
55420
US

IV. Provider business mailing address

900 WEST 94TH STREET
BLOOMINGTON MN
55420
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number103170
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103170
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: