Provider Demographics
NPI:1477879310
Name:HOLMSTROM, CARISSA R (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:R
Last Name:HOLMSTROM
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1846 OXFORD ST N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6523
Mailing Address - Country:US
Mailing Address - Phone:651-402-9179
Mailing Address - Fax:
Practice Address - Street 1:559 CAPITOL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2101
Practice Address - Country:US
Practice Address - Phone:651-232-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103724225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist