Provider Demographics
NPI:1205006764
Name:RAU, ANGELIQUE NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:NICOLE
Last Name:RAU
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12836 VERDIN ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1223
Mailing Address - Country:US
Mailing Address - Phone:763-755-3833
Mailing Address - Fax:
Practice Address - Street 1:12836 VERDIN ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1223
Practice Address - Country:US
Practice Address - Phone:763-755-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200121224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant