Provider Demographics
NPI:1326518150
Name:FORTIN, CAITLIN MARIE
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:FORTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 IRVING AVE S APT B
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2668
Mailing Address - Country:US
Mailing Address - Phone:952-261-7038
Mailing Address - Fax:
Practice Address - Street 1:201 E NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5714
Practice Address - Country:US
Practice Address - Phone:952-892-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105829225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist