=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164684635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA ELENA MORAN OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2008
-----------------------------------------------------
Last Update Date | 04/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 WOODDALE DR SUITE A.
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-4441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-738-9888
-----------------------------------------------------
Fax | 651-738-9889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 WOODDALE DR SUITE A.
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-4441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-738-9888
-----------------------------------------------------
Fax | 651-738-9889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 4642
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 104587
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------