Provider Demographics
NPI:1336791177
Name:KOPP, ADELYN RUTH (OTR/L)
Entity type:Individual
Prefix:
First Name:ADELYN
Middle Name:RUTH
Last Name:KOPP
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ADELYN
Other - Middle Name:RUTH
Other - Last Name:CONRATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:10137 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4500
Mailing Address - Country:US
Mailing Address - Phone:651-249-4705
Mailing Address - Fax:
Practice Address - Street 1:500 OSBORNE RD NE SUITE 365
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:763-236-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105256225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist