Provider Demographics
NPI:1073580502
Name:NORDLIE, MARY ROSE (OTR, CHT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ROSE
Last Name:NORDLIE
Suffix:
Gender:F
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1304
Mailing Address - Country:US
Mailing Address - Phone:952-941-0228
Mailing Address - Fax:
Practice Address - Street 1:8100 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4800
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100337225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN100337OtherSTATE OT LICENSE