Healthcare Provider Details

I. General information

NPI: 1134681703
Provider Name (Legal Business Name): REBECCA L MAGOON CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-3043
US

IV. Provider business mailing address

8941 WILDWOOD AVE
ST BONIFACIUS MN
55375-1124
US

V. Phone/Fax

Practice location:
  • Phone: 612-384-7651
  • Fax:
Mailing address:
  • Phone: 612-384-7651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: