Provider Demographics
NPI:1326802638
Name:DISTAD, LAUREN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:DISTAD
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13847 54TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55446-1651
Mailing Address - Country:US
Mailing Address - Phone:218-590-4915
Mailing Address - Fax:
Practice Address - Street 1:900 W 94TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4206
Practice Address - Country:US
Practice Address - Phone:952-885-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107372225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist