Provider Demographics
NPI:1538823745
Name:BERTRAM, VIOLA FAYE (COTA/L)
Entity type:Individual
Prefix:
First Name:VIOLA
Middle Name:FAYE
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3737
Mailing Address - Country:US
Mailing Address - Phone:320-979-1378
Mailing Address - Fax:
Practice Address - Street 1:500 PARK ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-3060
Practice Address - Country:US
Practice Address - Phone:320-274-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201488224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant