Healthcare Provider Details

I. General information

NPI: 1144587023
Provider Name (Legal Business Name): METRO THERAPY SPECIAL CHILDREN'S CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 E RIVER RD STE 403
FRIDLEY MN
55421-3777
US

IV. Provider business mailing address

5155 E RIVER RD STE 403
FRIDLEY MN
55421-3777
US

V. Phone/Fax

Practice location:
  • Phone: 762-572-2519
  • Fax: 763-572-2616
Mailing address:
  • Phone: 762-572-2519
  • Fax: 763-572-2616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. PATRICK TIMOTHY SULLIVAN
Title or Position: PRESIDENT
Credential:
Phone: 763-572-2519