Healthcare Provider Details

I. General information

NPI: 1205452125
Provider Name (Legal Business Name): KATIE MARIE COOLEY CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE MARIE WAKEMAN CMT

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 PARK AVE S STE 101
SAINT CLOUD MN
56301-6216
US

IV. Provider business mailing address

203 PARK AVE S STE 101
SAINT CLOUD MN
56301-6216
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5650
  • Fax: 320-253-9222
Mailing address:
  • Phone: 320-253-5650
  • Fax: 320-253-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: