Basic Information
| Provider Information | |||||||||
| NPI: | 1063897544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDBERG | ||||||||
| FirstName: | ELENE | ||||||||
| MiddleName: | EVYENIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNUDSEN | ||||||||
| OtherFirstName: | ELENE | ||||||||
| OtherMiddleName: | EVYENIA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5710 BAKER RD. | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527674200 | ||||||||
| FaxNumber: | 9527674211 | ||||||||
| Practice Location | |||||||||
| Address1: | 5710 BAKER RD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553455901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527674200 | ||||||||
| FaxNumber: | 9527674211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2015 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 104914 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 115000 | 05 | MN | MEDICAID |