Provider Demographics
NPI:1649365628
Name:ROBERTS, AILEEN M (OTR/CHT)
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OTR/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-6026
Mailing Address - Country:US
Mailing Address - Phone:320-629-6310
Mailing Address - Fax:320-629-4731
Practice Address - Street 1:1425 MAIN ST N
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-6026
Practice Address - Country:US
Practice Address - Phone:320-629-6310
Practice Address - Fax:320-629-4731
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103492225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40758300Medicaid