Provider Demographics
NPI:1508340480
Name:RUBIN, SHOSHANA (OT)
Entity Type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:
Last Name:RUBIN
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 1:2631 QUENTIN AVE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1958
Mailing Address - Country:US
Mailing Address - Phone:612-432-8226
Mailing Address - Fax:
Practice Address - Street 1:11140 HIGHWAY 55
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6016
Practice Address - Country:US
Practice Address - Phone:763-595-0812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105183225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty