=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720348014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH NORDIN MOTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2012
-----------------------------------------------------
Last Update Date | 10/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 7TH ST S
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-3444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-779-0866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5552 58TH ST S
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58104-5675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-779-0866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 104419
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 1267
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------