Provider Demographics
NPI:1235301532
Name:ANDERSON, ELYSE CELINE (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:CELINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 MAPLEWOOD DRIVE
Mailing Address - Street 2:SUITE 313
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1913
Mailing Address - Country:US
Mailing Address - Phone:651-770-8884
Mailing Address - Fax:651-770-8151
Practice Address - Street 1:2495 MAPLEWOOD DRIVE
Practice Address - Street 2:SUITE 313
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1913
Practice Address - Country:US
Practice Address - Phone:651-770-8884
Practice Address - Fax:651-770-8151
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103553225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics