Provider Demographics
NPI:1598110439
Name:TILSEN, ANGELA (COTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:TILSEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 SPRUCE PL
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4734
Mailing Address - Country:US
Mailing Address - Phone:651-210-3507
Mailing Address - Fax:
Practice Address - Street 1:4415 W 36 1/2 ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4854
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202112225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist