Provider Demographics
NPI:1962992156
Name:HRUBETZ, CARISA BETHANY (OT)
Entity type:Individual
Prefix:
First Name:CARISA
Middle Name:BETHANY
Last Name:HRUBETZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CARISA
Other - Middle Name:BETHANY
Other - Last Name:HILLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:11800 XEON BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2099
Mailing Address - Country:US
Mailing Address - Phone:763-755-8400
Mailing Address - Fax:763-755-8578
Practice Address - Street 1:11800 XEON BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-2061
Practice Address - Country:US
Practice Address - Phone:763-755-8400
Practice Address - Fax:763-755-8575
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNOT-105351225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1962499566Medicaid
MNOT-105351OtherSTATE LICENSE