Provider Demographics
NPI:1366201626
Name:ANDERSON, JOANNA NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4786 CARRICK RD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1873
Mailing Address - Country:US
Mailing Address - Phone:612-601-6197
Mailing Address - Fax:
Practice Address - Street 1:1861 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1293
Practice Address - Country:US
Practice Address - Phone:952-240-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106436225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist