Healthcare Provider Details

I. General information

NPI: 1487240693
Provider Name (Legal Business Name): PRESCOTT THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2020
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL STE 1947
MINNEAPOLIS MN
55402-2707
US

IV. Provider business mailing address

18872 42ND AVE N
PLYMOUTH MN
55446-3068
US

V. Phone/Fax

Practice location:
  • Phone: 952-200-0215
  • Fax: 833-499-1896
Mailing address:
  • Phone: 952-807-7312
  • Fax:

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: TRAVIS JOHN KIERSTEAD
Title or Position: MANAGING MEMBER
Credential: PT
Phone: 952-807-7312