Provider Demographics
NPI:1235174202
Name:PIERCE, CAROLYN GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:GRACE
Last Name:PIERCE
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 1:33656 S COTTON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHERT
Mailing Address - State:MN
Mailing Address - Zip Code:56578-9688
Mailing Address - Country:US
Mailing Address - Phone:218-846-2338
Mailing Address - Fax:
Practice Address - Street 1:803 ROOSEVELT AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3744
Practice Address - Country:US
Practice Address - Phone:218-844-5555
Practice Address - Fax:218-844-6057
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2109395OtherFIRST HEALTH
MN64-04595OtherMEDICA HEALTH INS.
MNP00086020OtherRAILROAD MEDICARE
MN005J1PIOtherBLUECROSSBLUESHIELD-MN