Provider Demographics
NPI:1730524224
Name:BRUESEHOFF, BETHANY L (COTA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:L
Last Name:BRUESEHOFF
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 168TH CIR NE
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5418
Mailing Address - Country:US
Mailing Address - Phone:763-413-3172
Mailing Address - Fax:
Practice Address - Street 1:3130 GRIMES AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-3217
Practice Address - Country:US
Practice Address - Phone:763-450-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200575224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant