Basic Information
| Provider Information | |||||||||
| NPI: | 1114390523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEA | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | MARTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9220 BASS LAKE RD | ||||||||
| Address2: | #260 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554283000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9220 BASS LAKE RD | ||||||||
| Address2: | #260 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554283000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2015 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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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 | 104969 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.