Healthcare Provider Details

I. General information

NPI: 1093356883
Provider Name (Legal Business Name): MONTAE BAILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7106 OHMS LN
EDINA MN
55439-2140
US

IV. Provider business mailing address

7106 OHMS LN
EDINA MN
55439-2140
US

V. Phone/Fax

Practice location:
  • Phone: 612-275-6179
  • Fax:
Mailing address:
  • Phone: 612-275-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: