MEDICARE: KERRY GLIDDEN COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	201256	MN

General Provider Information

NPI Number	:	1255756888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY GLIDDEN COTA/L

Provider Business Mailing Address
First Line	:	826 74 1/2 AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55444-2620
Country	:	US
Telephone Number	:	612-327-1672
Fax Number	:

Provider Business Practice Location Address
First Line	:	826 74 1/2 AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55444-2620
Country	:	US
Telephone Number	:	612-327-1672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	02/18/2014

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Directions to “ KERRY GLIDDEN COTA/L” Practice Location

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