Provider Demographics
NPI:1801287081
Name:PETRICKA, KALLIE (OTR/L)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:PETRICKA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 COBBLESTONE LANE
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044
Mailing Address - Country:US
Mailing Address - Phone:952-460-4987
Mailing Address - Fax:
Practice Address - Street 1:3305 CENTRAL PARK VILLAGE DR STE 130
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-7707
Practice Address - Country:US
Practice Address - Phone:651-406-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X
MN104754225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics