Provider Demographics
NPI:1306482195
Name:ERVIN, MICHELLE KATHLEEN (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:ERVIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8525 CHANHASSEN HILLS DR S
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8108
Mailing Address - Country:US
Mailing Address - Phone:612-247-7938
Mailing Address - Fax:
Practice Address - Street 1:800 BOONE AVE N STE 135
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4476
Practice Address - Country:US
Practice Address - Phone:763-334-7994
Practice Address - Fax:763-267-6653
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100238225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty