Provider Demographics
NPI:1427494160
Name:BOTHUN, CHRISTINE URSEL (OTR)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:URSEL
Last Name:BOTHUN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-5316
Mailing Address - Country:US
Mailing Address - Phone:507-429-7249
Mailing Address - Fax:
Practice Address - Street 1:403 E LAKE BLVD
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-5316
Practice Address - Country:US
Practice Address - Phone:507-429-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3791-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3791-26OtherOCCUPATIONAL THERAPY WISCONSIN LICENSE-