Provider Demographics
NPI:1548042229
Name:MINNIS, KRISTA JO (OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JO
Last Name:MINNIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6006 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-5489
Mailing Address - Country:US
Mailing Address - Phone:805-844-8758
Mailing Address - Fax:
Practice Address - Street 1:1525 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6425
Practice Address - Country:US
Practice Address - Phone:989-835-6333
Practice Address - Fax:989-835-3235
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006485225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics