Healthcare Provider Details

I. General information

NPI: 1639611494
Provider Name (Legal Business Name): BREANNA ROSE VINOSKI MOT, R/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3395 PLYMOUTH RD
MINNETONKA MN
55305-3765
US

IV. Provider business mailing address

3395 PLYMOUTH RD
MINNETONKA MN
55305-3765
US

V. Phone/Fax

Practice location:
  • Phone: 952-548-8761
  • Fax:
Mailing address:
  • Phone: 952-548-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5400
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: