Healthcare Provider Details

I. General information

NPI: 1255734349
Provider Name (Legal Business Name): HALLIE LUCERO NOYOLA MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5868 BAKER RD
MINNETONKA MN
55345-5903
US

IV. Provider business mailing address

LOT 4174 PO BOX 17370
SAINT PAUL MN
55117
US

V. Phone/Fax

Practice location:
  • Phone: 612-928-5331
  • Fax:
Mailing address:
  • Phone: 651-587-6602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number104208
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: