=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083599112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATI RILEY WAALK OTD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2025
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9220 BASS LAKE RD STE 260
-----------------------------------------------------
City | NEW HOPE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55428-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-553-0363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4425 GOLDENROD LN N
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55442-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-619-7758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 107887
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 107887
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------