Provider Demographics
NPI:1295273944
Name:ROELL, AMY (OTR)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ROELL
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 1:3212 119TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-7514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 S DELLWOOD STREET
Practice Address - Street 2:MAIL ROUTE 71000
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008
Practice Address - Country:US
Practice Address - Phone:763-688-8043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102365225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist