Provider Demographics
NPI:1497328918
Name:PEMBERTON, OLIVIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:PEMBERTON
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 1:16360 HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:NEW GERMANY
Mailing Address - State:MN
Mailing Address - Zip Code:55367-9510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1095 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-5000
Practice Address - Country:US
Practice Address - Phone:320-484-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104340225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation