Provider Demographics
NPI:1114454188
Name:KOETHE, AMANDA RAE (OTR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:KOETHE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 DUTCH LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349-5435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4050 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2522
Practice Address - Country:US
Practice Address - Phone:763-236-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-21
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist