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General NPI Number Information
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NPI Number | 1467875294
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Entity Type | Organization
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Legal Business Name | LISA SANDSTROM LLC
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Dates
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Enumeration Date | 01/30/2014
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Last Update Date | 01/30/2014
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Provider Practice Location Address
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Address Line | 202 GREELEY ST N
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City | STILLWATER
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State | MN
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Zip | 55082-4711
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Country | US
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Telephone | 651-238-0435
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Fax | 651-439-9434
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Provider Business Mailing Address
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Address Line | 202 GREELEY ST N
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City | STILLWATER
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State | MN
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Zip | 55082-4711
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Country | US
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Telephone | 651-238-0435
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Fax | 651-439-9434
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | LISA SANDSTROM
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Credential |
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Telephone | 651-238-0435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 103330
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License Number State | MN
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