Provider Demographics
NPI:1104624550
Name:DICKASON-SOPETH, LAURA JEAN (OTR)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:DICKASON-SOPETH
Suffix:
Gender:
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17420 IXONIA CT
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8741
Mailing Address - Country:US
Mailing Address - Phone:612-280-3514
Mailing Address - Fax:
Practice Address - Street 1:8758 EGAN DR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2561
Practice Address - Country:US
Practice Address - Phone:952-473-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100665225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist