Basic Information
Provider Information | |||||||||
NPI: | 1225622772 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | ERYN | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KITTOCK | ||||||||
OtherFirstName: | ERYN | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1702 UNIVERSITY DR S | ||||||||
Address2: | MEDICAL STAFF SERVICE | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581034940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013644999 | ||||||||
FaxNumber: | 7013648476 | ||||||||
Practice Location | |||||||||
Address1: | 407 E 3RD ST | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558051950 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187864000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/25/2021 | ||||||||
LastUpdateDate: | 01/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5821 | MN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225XP0019X | 106491 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
ID Information
ID | Type | State | Issuer | Description | 106491 | 01 | MN | MN BOARD OF OCCUPATIONAL THERAPY | OTHER | 1225622772 | 01 | MN | NPI | OTHER |