Provider Demographics
NPI:1821368184
Name:MELBOSTAD, ASHLEY S (OT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:S
Last Name:MELBOSTAD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 NORTHDALE BLVD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3045
Mailing Address - Country:US
Mailing Address - Phone:763-755-5495
Mailing Address - Fax:763-862-0342
Practice Address - Street 1:2104 NORTHDALE BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3045
Practice Address - Country:US
Practice Address - Phone:763-755-5495
Practice Address - Fax:763-862-0342
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056-009472Other056-009472