Provider Demographics
NPI:1205378528
Name:KIRKPATRICK, MYRIA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MYRIA
Middle Name:
Last Name:KIRKPATRICK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 W 25 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1717
Mailing Address - Country:US
Mailing Address - Phone:612-508-4980
Mailing Address - Fax:
Practice Address - Street 1:800 BOONE AVE N
Practice Address - Street 2:200
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4468
Practice Address - Country:US
Practice Address - Phone:763-417-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201981224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant