Provider Demographics
NPI:1205971710
Name:PHELPS, KRISTA MARIE (OTR)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:MARIE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:KRISTA
Other - Middle Name:MARIE
Other - Last Name:THOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:3862 GOODWIN AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3020
Mailing Address - Country:US
Mailing Address - Phone:651-770-8884
Mailing Address - Fax:651-770-8151
Practice Address - Street 1:2495 MAPLEWOOD DR
Practice Address - Street 2:SUITE 313
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1984
Practice Address - Country:US
Practice Address - Phone:651-770-8884
Practice Address - Fax:651-770-8151
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102751225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics