Provider Demographics
NPI:1558592535
Name:SPEIDEL, KARA JO (MSOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KARA
Middle Name:JO
Last Name:SPEIDEL
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:MS
Other - First Name:KARA
Other - Middle Name:JO
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6400 SYCAMORE LN N APT 309
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6377
Mailing Address - Country:US
Mailing Address - Phone:701-870-1775
Mailing Address - Fax:
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4249
Practice Address - Country:US
Practice Address - Phone:763-520-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103864225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist