Healthcare Provider Details

I. General information

NPI: 1669601399
Provider Name (Legal Business Name): MAI TONG THAO O.T.R/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 GALTIER ST
SAINT PAUL MN
55103-2358
US

IV. Provider business mailing address

5959 CANDACE AVE
INVER GROVE HEIGHTS MN
55076-4487
US

V. Phone/Fax

Practice location:
  • Phone: 651-224-1848
  • Fax:
Mailing address:
  • Phone: 651-270-3562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103628
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: