Healthcare Provider Details

I. General information

NPI: 1083599112
Provider Name (Legal Business Name): KATI RILEY WAALK OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 BASS LAKE RD STE 260
NEW HOPE MN
55428-3019
US

IV. Provider business mailing address

4425 GOLDENROD LN N
PLYMOUTH MN
55442-2766
US

V. Phone/Fax

Practice location:
  • Phone: 763-553-0363
  • Fax:
Mailing address:
  • Phone: 612-619-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number107887
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number107887
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: