Provider Demographics
NPI:1265545776
Name:GROTH, KRISTEEN LAURA (OTR)
Entity type:Individual
Prefix:
First Name:KRISTEEN
Middle Name:LAURA
Last Name:GROTH
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 1:1768 OAKWOOD DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4939
Mailing Address - Country:US
Mailing Address - Phone:612-730-8272
Mailing Address - Fax:866-409-6687
Practice Address - Street 1:1768 OAKWOOD DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-4939
Practice Address - Country:US
Practice Address - Phone:612-730-8272
Practice Address - Fax:866-409-6687
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN729440900Medicaid
MN392L4BOOtherBCBS
MN181587OtherUCARE
MN392L4BOOtherBCBS