Healthcare Provider Details

I. General information

NPI: 1326308065
Provider Name (Legal Business Name): GLOBAL ATHLETE VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 05/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W 98TH ST
BLOOMINGTON MN
55431-2746
US

IV. Provider business mailing address

PO BOX 20725
BLOOMINGTON MN
55420-0725
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-4311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code364SN0800X
TaxonomyNeuroscience Clinical Nurse Specialist
License Number
License Number StateMN
# 10
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMN

VIII. Authorized Official

Name: STEPHANIE SMITH
Title or Position: CEO
Credential: ATC
Phone: 952-888-4311