Provider Demographics
NPI:1851442172
Name:VANG, MARCHELL MOXA (OTD OTRL)
Entity Type:Individual
Prefix:
First Name:MARCHELL
Middle Name:MOXA
Last Name:VANG
Suffix:
Gender:F
Credentials:OTD OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 64TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2236
Mailing Address - Country:US
Mailing Address - Phone:763-566-3244
Mailing Address - Fax:
Practice Address - Street 1:14050 NICOLLET AVE STE 201
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5738
Practice Address - Country:US
Practice Address - Phone:952-993-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103116225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics