Provider Demographics
NPI:1619666336
Name:SIMON, PETER THOMAS (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:THOMAS
Last Name:SIMON
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 91ST CRES N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3831
Mailing Address - Country:US
Mailing Address - Phone:763-381-7437
Mailing Address - Fax:
Practice Address - Street 1:380 OAK GROVE PKWY
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-8508
Practice Address - Country:US
Practice Address - Phone:952-767-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107127225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist