Healthcare Provider Details

I. General information

NPI: 1619652187
Provider Name (Legal Business Name): CARLEE MICHELLE MARTIN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 W 81ST ST STE 112
BLOOMINGTON MN
55437-1111
US

IV. Provider business mailing address

4801 W 81ST ST STE 112
BLOOMINGTON MN
55437-1111
US

V. Phone/Fax

Practice location:
  • Phone: 952-345-3000
  • Fax: 952-345-6789
Mailing address:
  • Phone: 952-345-3000
  • Fax: 523-456-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13314
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: