Healthcare Provider Details

I. General information

NPI: 1437703311
Provider Name (Legal Business Name): REBECCA LAIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

IV. Provider business mailing address

109 N FAIRLAND ST
PRYOR OK
74361-4203
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1454
  • Fax: 612-871-1505
Mailing address:
  • Phone: 918-825-1405
  • Fax: 918-825-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: