Basic Information
| Provider Information | |||||||||
| NPI: | 1093113144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GJELLSTAD | ||||||||
| FirstName: | MATIA | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5020 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587025020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575000 | ||||||||
| FaxNumber: | 7018575646 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 3RD AVE SW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587013880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575286 | ||||||||
| FaxNumber: | 7018575694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2014 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1268 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.