Provider Demographics
NPI:1982018289
Name:LIST, ANDREA (OT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 GIRARD AVE S
Mailing Address - Street 2:APT 1
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2535
Mailing Address - Country:US
Mailing Address - Phone:715-575-5671
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5505-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist