Healthcare Provider Details

I. General information

NPI: 1972116036
Provider Name (Legal Business Name): ABIGAIL WHILLOCK OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 E LAKE ST
MINNEAPOLIS MN
55407-6700
US

IV. Provider business mailing address

1527 E LAKE ST
MINNEAPOLIS MN
55407-6700
US

V. Phone/Fax

Practice location:
  • Phone: 605-216-9887
  • Fax:
Mailing address:
  • Phone: 763-521-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number106303
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: