=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962479501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN E WALTS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2006
-----------------------------------------------------
Last Update Date | 08/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14100 CARLSON PKWY STE 200
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-519-7900
-----------------------------------------------------
Fax | 763-450-0202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1939 MINNEHAHA AVE W STE 300
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-748-4338
-----------------------------------------------------
Fax | 651-748-2892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 7419
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------