Healthcare Provider Details

I. General information

NPI: 1033941091
Provider Name (Legal Business Name): KARA DAAVETTILA MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 N 3RD ST
BISMARCK ND
58501-3556
US

IV. Provider business mailing address

PO BOX 2536
BISMARCK ND
58502-2536
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-1569
  • Fax: 701-223-1669
Mailing address:
  • Phone: 701-258-1569
  • Fax: 701-223-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2112
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: