Provider Demographics
NPI:1053402966
Name:HENNEN, MARIA (OTR)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:HENNEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:MANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5033 ROSE CREEK PKWY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5033 ROSE CREEK PKWY S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6848
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100794225X00000X
ND365225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6411124OtherMEDICA
ND15166OtherBCBS
MN5G717MAOtherBCBS
MN6411124OtherMEDICA