Provider Demographics
NPI:1598075541
Name:MOOTHEDAN, TAMMY JOANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JOANNE
Last Name:MOOTHEDAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:JOANNE
Other - Last Name:LAZZARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1629 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-1571
Mailing Address - Country:US
Mailing Address - Phone:651-404-1399
Mailing Address - Fax:
Practice Address - Street 1:1629 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1571
Practice Address - Country:US
Practice Address - Phone:715-307-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN999386225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist