Provider Demographics
NPI:1396858452
Name:PARK, REBECCA M (OT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:PARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 OXBOROUGH CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3995
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:SUITE 450
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2111
Practice Address - Country:US
Practice Address - Phone:952-908-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263999800Medicaid