Healthcare Provider Details

I. General information

NPI: 1629724745
Provider Name (Legal Business Name): ELIZABETH R SANDELL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 99TH AVE N
MAPLE GROVE MN
55369-4730
US

IV. Provider business mailing address

4401 PARK GLEN RD APT 349
ST LOUIS PARK MN
55416-4769
US

V. Phone/Fax

Practice location:
  • Phone: 763-898-1114
  • Fax:
Mailing address:
  • Phone: 952-210-7404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number104497
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: