Healthcare Provider Details

I. General information

NPI: 1629474713
Provider Name (Legal Business Name): BLUE SKY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 FRONT ST
BRAINERD MN
56401-3516
US

IV. Provider business mailing address

29320 COUNTY ROAD 26
BROWERVILLE MN
56438-0000
US

V. Phone/Fax

Practice location:
  • Phone: 405-642-9469
  • Fax:
Mailing address:
  • Phone: 405-642-9469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number8645
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number8645
License Number StateMN

VIII. Authorized Official

Name: MISS LORI HAGOOD
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 405-642-9469