Healthcare Provider Details

I. General information

NPI: 1396475927
Provider Name (Legal Business Name): MARY T OUTPATIENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 XEON BLVD NW
COON RAPIDS MN
55448-2061
US

IV. Provider business mailing address

1555 118TH LN NW STE 1
COON RAPIDS MN
55448-7500
US

V. Phone/Fax

Practice location:
  • Phone: 763-489-3638
  • Fax: 763-647-3885
Mailing address:
  • Phone: 763-219-7491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JASON TJOSVOLD
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 763-567-8951