Provider Demographics
NPI:1093775215
Name:KLEINWACHTER, SHIRLEY MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:MARIE
Last Name:KLEINWACHTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17001 168TH ST SE
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-4574
Mailing Address - Country:US
Mailing Address - Phone:763-263-7460
Mailing Address - Fax:
Practice Address - Street 1:1107 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8538
Practice Address - Country:US
Practice Address - Phone:763-295-6878
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1637Medicare UPIN