Provider Demographics
NPI:1154851053
Name:MEYER, MARYSA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARYSA
Middle Name:
Last Name:MEYER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 LEXINGTON AVE N # 286
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6522
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:
Practice Address - Street 1:3912 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:877-709-1090
Practice Address - Fax:866-221-3400
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist