Provider Demographics
NPI:1700622206
Name:AHMANN, JUSTINE (COTA/L)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:AHMANN
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 1:877 120TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2273
Mailing Address - Country:US
Mailing Address - Phone:763-439-3499
Mailing Address - Fax:
Practice Address - Street 1:5200 OAK GROVE PKWY N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-4031
Practice Address - Country:US
Practice Address - Phone:763-439-3499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202204224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant