Healthcare Provider Details

I. General information

NPI: 1891635769
Provider Name (Legal Business Name): ANGELA MARIE DIAZ OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 210TH ST N
FOREST LAKE MN
55025-9617
US

IV. Provider business mailing address

9951 STACY TRL
CHISAGO CITY MN
55013-9531
US

V. Phone/Fax

Practice location:
  • Phone: 651-982-8100
  • Fax:
Mailing address:
  • Phone: 651-335-7919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number101785
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: