Basic Information
| Provider Information | |||||||||
| NPI: | 1477861243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOMAN | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDRICKSON | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 309 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562781357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205855395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
| 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 | 103898 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.