Provider Demographics
NPI:1396073995
Name:SMITH, DEBRA RUTH (OTR/L)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:RUTH
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:RUTH
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:9645 GROVE CIR N STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2684
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:
Practice Address - Street 1:320 COON RAPIDS BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5640
Practice Address - Country:US
Practice Address - Phone:952-908-2580
Practice Address - Fax:952-908-2581
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103798225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist