Healthcare Provider Details

I. General information

NPI: 1760789218
Provider Name (Legal Business Name): MISTY MARIE FARRELLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY HLAVA

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 SUBURBAN AVE
SAINT PAUL MN
55106-6636
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number37453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: