Healthcare Provider Details

I. General information

NPI: 1982294542
Provider Name (Legal Business Name): ANDERS WALLOCK MOT, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 FORD PKWY STE 200
SAINT PAUL MN
55116-3412
US

IV. Provider business mailing address

2270 FORD PKWY STE 200
SAINT PAUL MN
55116-3412
US

V. Phone/Fax

Practice location:
  • Phone: 651-696-5010
  • Fax:
Mailing address:
  • Phone: 651-696-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number106414
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: