Healthcare Provider Details

I. General information

NPI: 1902963663
Provider Name (Legal Business Name): KATHRYN ANN GORRES NICE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE NICE

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD SUITE 255
MINNEAPOLIS MN
55416-1222
US

IV. Provider business mailing address

5775 WAYZATA BLVD SUITE 255
MINNEAPOLIS MN
55416-1222
US

V. Phone/Fax

Practice location:
  • Phone: 952-525-4500
  • Fax:
Mailing address:
  • Phone: 952-525-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number102378
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: