Healthcare Provider Details

I. General information

NPI: 1457963191
Provider Name (Legal Business Name): TRESSA DEE WEEDEN-BOOTZ CMT, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRESSA LEMAY

II. Dates (important events)

Enumeration Date: 08/22/2020
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date: 04/12/2021
Reactivation Date: 12/27/2023

III. Provider practice location address

112 W 2ND ST
CHASKA MN
55318-2635
US

IV. Provider business mailing address

112 W 2ND ST
CHASKA MN
55318-2635
US

V. Phone/Fax

Practice location:
  • Phone: 952-220-5938
  • Fax:
Mailing address:
  • Phone: 952-220-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number00000000
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number00000000
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: