Healthcare Provider Details

I. General information

NPI: 1750626958
Provider Name (Legal Business Name): MICHELLE MARIE VANDER LINDEN C.O.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 7TH ST W
SAINT PAUL MN
55116-2813
US

IV. Provider business mailing address

1613 REDWOOD DR APT 201
HUDSON WI
54016-9243
US

V. Phone/Fax

Practice location:
  • Phone: 651-698-0793
  • Fax:
Mailing address:
  • Phone: 612-242-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number201718
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4774-027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: