Healthcare Provider Details

I. General information

NPI: 1477640613
Provider Name (Legal Business Name): FUNCTIONAL INTEGRATED THERAPY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 MAPLEWOOD DRIVE SUITE 313
MAPLEWOOD MN
55109-1913
US

IV. Provider business mailing address

2495 MAPLEWOOD DRIVE SUITE 313
MAPLEWOOD MN
55109-1913
US

V. Phone/Fax

Practice location:
  • Phone: 651-770-8884
  • Fax: 651-770-8151
Mailing address:
  • Phone: 651-770-8884
  • Fax: 651-770-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number100591
License Number StateMN

VIII. Authorized Official

Name: KRISTI KAY WORRELL
Title or Position: OWNER/OPERATOR
Credential: OTR/L
Phone: 651-770-8884