Healthcare Provider Details

I. General information

NPI: 1487579322
Provider Name (Legal Business Name): KACI LAINE WILMER MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 3RD ST NE
ROSEAU MN
56751-1113
US

IV. Provider business mailing address

715 DELMORE DR
ROSEAU MN
56751-1599
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-1471
  • Fax:
Mailing address:
  • Phone: 218-463-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number105206
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: