Provider Demographics
NPI:1942445390
Name:REWALD, KRIS ANTONI (COTA)
Entity Type:Individual
Prefix:MR
First Name:KRIS
Middle Name:ANTONI
Last Name:REWALD
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:271 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4824
Mailing Address - Country:US
Mailing Address - Phone:651-484-9475
Mailing Address - Fax:
Practice Address - Street 1:7505 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4501
Practice Address - Country:US
Practice Address - Phone:763-545-0416
Practice Address - Fax:763-545-2016
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201196224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant