Provider Demographics
NPI:1689202483
Name:ALI, MAYAR SAMI (COTA)
Entity Type:Individual
Prefix:
First Name:MAYAR
Middle Name:SAMI
Last Name:ALI
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 MANCHESTER AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 E MEDICINE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2307
Practice Address - Country:US
Practice Address - Phone:612-200-7352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202001224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant