Provider Demographics
NPI:1639634074
Name:ZIMMERMAN, ALYCE MIRINDA (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYCE
Middle Name:MIRINDA
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41077 474TH AVE
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-8980
Mailing Address - Country:US
Mailing Address - Phone:218-205-5030
Mailing Address - Fax:
Practice Address - Street 1:503 BENZEL AVE SW
Practice Address - Street 2:
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1603
Practice Address - Country:US
Practice Address - Phone:218-205-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102834225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist