Provider Demographics
NPI:1720105331
Name:SKOGEN, DIANA LYNN (OTRL)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:SKOGEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44070 220TH ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:MN
Mailing Address - Zip Code:56023-5473
Mailing Address - Country:US
Mailing Address - Phone:507-525-3195
Mailing Address - Fax:
Practice Address - Street 1:44070 220TH ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:MN
Practice Address - Zip Code:56023-6814
Practice Address - Country:US
Practice Address - Phone:507-525-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100274225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130009100Medicaid
MN185D9SKOtherBLUE CROSS BLUE SHIELD
MN130009100Medicaid