Provider Demographics
NPI:1841414794
Name:MARTEN, ALICIA JO (OTR)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:JO
Last Name:MARTEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 180TH LN NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-1015
Mailing Address - Country:US
Mailing Address - Phone:763-432-2484
Mailing Address - Fax:
Practice Address - Street 1:300 COON RAPIDS BLVD NW STE 200
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5645
Practice Address - Country:US
Practice Address - Phone:763-767-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103189225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist