Provider Demographics
NPI:1467659839
Name:SANDSTROM, LISA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SANDSTROM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 SAINT CROIX TRL N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-4267
Mailing Address - Country:US
Mailing Address - Phone:651-238-0435
Mailing Address - Fax:651-383-4544
Practice Address - Street 1:6381 OSGOOD AVE N BLDG C
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6118
Practice Address - Country:US
Practice Address - Phone:651-238-0435
Practice Address - Fax:651-383-4544
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103330225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN670000488OtherMEDICARE PTAN