Basic Information
Provider Information | |||||||||
NPI: | 1184791972 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AUSMAN | ||||||||
FirstName: | BETH | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, OTRL | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LERNER | ||||||||
OtherFirstName: | BETH | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6123 W 140TH ST | ||||||||
Address2: |   | ||||||||
City: | SAVAGE | ||||||||
State: | MN | ||||||||
PostalCode: | 553781937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9522265154 | ||||||||
FaxNumber: | 6127285354 | ||||||||
Practice Location | |||||||||
Address1: | 3333 UNIVERSITY AVE SE | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554143325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6127285396 | ||||||||
FaxNumber: | 6127285354 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 103218 | MN | X |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225XP0200X | 103218 | MN | X |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 082H6AU | 01 | MN | BLUE CROSS | OTHER |