Provider Demographics
NPI:1841497096
Name:ROOT, STEPHEN THOMAS (OTR)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:THOMAS
Last Name:ROOT
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 2ND ST
Mailing Address - Street 2:APT#B2
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1967
Mailing Address - Country:US
Mailing Address - Phone:952-403-3923
Mailing Address - Fax:952-403-3979
Practice Address - Street 1:1661 PARK RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2841
Practice Address - Country:US
Practice Address - Phone:952-403-3980
Practice Address - Fax:952-403-3979
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102626225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist