Provider Demographics
NPI:1710474564
Name:MINARIK, ELLEN JUDITH (OTR)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JUDITH
Last Name:MINARIK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:JUDITH
Other - Last Name:MCCRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-2424
Mailing Address - Country:US
Mailing Address - Phone:608-263-8060
Mailing Address - Fax:608-262-7679
Practice Address - Street 1:9680 TAMARACK RD STE 130
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2623
Practice Address - Country:US
Practice Address - Phone:612-273-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6151-26225X00000X
MN105579225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist