MEDICARE: BECKY MARIE EDSON OTR

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	225XP0200X	Pediatric Occupational Therapist	101560	MN

General Provider Information

NPI Number	:	1639459167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BECKY MARIE EDSON OTR

Provider Business Mailing Address
First Line	:	4984 381ST LN
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6075
Country	:	US
Telephone Number	:	651-237-0387
Fax Number	:

Provider Business Practice Location Address
First Line	:	4984 381ST LN
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6075
Country	:	US
Telephone Number	:	651-237-0387
Fax Number	:

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

Provider Enumeration Date	:	08/29/2011
Last Update Date	:	08/29/2011

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