Healthcare Provider Details

I. General information

NPI: 1194746743
Provider Name (Legal Business Name): MARNY TERESE FARRELL MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST MAIL STOP 11102D
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST MAIL STOP 11102D
SAINT PAUL MN
55101-2502
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-2032
  • Fax: 651-254-0910
Mailing address:
  • Phone: 651-254-2032
  • Fax: 651-254-0910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7382
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: