Healthcare Provider Details

I. General information

NPI: 1730835257
Provider Name (Legal Business Name): ACTIVE THERAPY MN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 HENNEPIN TOWN RD
EDEN PRAIRIE MN
55347-5100
US

IV. Provider business mailing address

6633 N LINCOLN AVE
LINCOLNWOOD IL
60712-3605
US

V. Phone/Fax

Practice location:
  • Phone: 612-562-8204
  • Fax: 763-328-0111
Mailing address:
  • Phone: 612-562-8204
  • Fax: 763-328-0111

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
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SHELDON HOLLANDER
Title or Position: MANAGING MEMBER
Credential:
Phone: 612-562-8204