Provider Demographics
NPI:1013026384
Name:JOSEPHSON, KEVIN TODD (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:TODD
Last Name:JOSEPHSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4067 HALITE LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2924
Mailing Address - Country:US
Mailing Address - Phone:651-675-6163
Mailing Address - Fax:
Practice Address - Street 1:4067 HALITE LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2924
Practice Address - Country:US
Practice Address - Phone:651-675-6163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7405OtherLICENSE #