Provider Demographics
NPI:1194186049
Name:VIDAL, KATHRYN ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:VIDAL
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 1:200 LEWIS AVE S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WATERTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55388-4545
Mailing Address - Country:US
Mailing Address - Phone:952-955-2242
Mailing Address - Fax:952-955-2010
Practice Address - Street 1:135 GERANIUM AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-5007
Practice Address - Country:US
Practice Address - Phone:651-272-4501
Practice Address - Fax:651-488-7408
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104200225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology