Healthcare Provider Details

I. General information

NPI: 1942633060
Provider Name (Legal Business Name): ANNA LEA BROMELAND OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 MCDEVITT ST
SHAKOPEE MN
55379-2248
US

IV. Provider business mailing address

530 MCDEVITT ST
SHAKOPEE MN
55379-2248
US

V. Phone/Fax

Practice location:
  • Phone: 612-385-1896
  • Fax:
Mailing address:
  • Phone: 612-385-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number103344
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: