Provider Demographics
NPI:1689869604
Name:FRIEDE, TRACI (OTRL)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:FRIEDE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4058 DEERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1889
Mailing Address - Country:US
Mailing Address - Phone:651-994-9644
Mailing Address - Fax:651-994-8962
Practice Address - Street 1:14635 PENNOCK AVE
Practice Address - Street 2:SUITE #300
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6430
Practice Address - Country:US
Practice Address - Phone:952-997-2823
Practice Address - Fax:952-997-6931
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103493225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8D301FROtherBCBS