Provider Demographics
NPI:1245609213
Name:BOUGHNER, EMILY A (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:BOUGHNER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:TERHAAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1891 STATION PARKWAY NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4259
Mailing Address - Country:US
Mailing Address - Phone:763-755-4275
Mailing Address - Fax:763-755-4261
Practice Address - Street 1:15590 90TH ST NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-9452
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:763-755-4261
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104970225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics