Healthcare Provider Details

I. General information

NPI: 1669522421
Provider Name (Legal Business Name): JANE ELISABETH AAFEDT MCCOY MOTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 11TH ST. SO.
FARGO ND
58103-7417
US

IV. Provider business mailing address

3001 11TH ST. SO.
FARGO ND
58103-7417
US

V. Phone/Fax

Practice location:
  • Phone: 701-356-0062
  • Fax: 701-356-5412
Mailing address:
  • Phone: 701-356-0062
  • Fax: 701-356-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number947
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number103187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: