Provider Demographics
NPI:1659573657
Name:OPHAUG, LYNNETTE RENEE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LYNNETTE
Middle Name:RENEE
Last Name:OPHAUG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:LYNNETTE
Other - Middle Name:RENEE
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:225 PRAIRIE VIEW DR APT 11215
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-7140
Mailing Address - Country:US
Mailing Address - Phone:218-791-7521
Mailing Address - Fax:
Practice Address - Street 1:2602 FIFIELD RD
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-7925
Practice Address - Country:US
Practice Address - Phone:641-458-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103462225X00000X
ND933225X00000X
IA110486225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist