Healthcare Provider Details

I. General information

NPI: 1992630156
Provider Name (Legal Business Name): LAURA BODURTHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4848 GATEWAY BLVD
MAPLE PLAIN MN
55359-4405
US

IV. Provider business mailing address

7365 HOWARD LN APT 320
EDEN PRAIRIE MN
55346-3039
US

V. Phone/Fax

Practice location:
  • Phone: 763-479-8021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number105642
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: