Healthcare Provider Details

I. General information

NPI: 1962609511
Provider Name (Legal Business Name): DIANE M STOLTENBERG OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE M RUDER OTR L

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 ROWE AVE
WORTHINGTON MN
56187-9700
US

IV. Provider business mailing address

1530 ROWE AVE
WORTHINGTON MN
56187-9700
US

V. Phone/Fax

Practice location:
  • Phone: 507-372-2232
  • Fax: 507-372-7326
Mailing address:
  • Phone: 507-372-2232
  • Fax: 507-372-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103211
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: