Healthcare Provider Details

I. General information

NPI: 1063965507
Provider Name (Legal Business Name): AMY CARLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8758 EGAN DR
SAVAGE MN
55378-2561
US

IV. Provider business mailing address

PO BOX 34 1772 STIEGER LAKE LANE
VICTORIA MN
55386-0034
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-9888
  • Fax: 952-443-9804
Mailing address:
  • Phone: 952-443-9888
  • Fax: 952-443-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number103530
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: