Provider Demographics
NPI:1235687005
Name:BRENTESON, CHARLOTTE (PT)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:BRENTESON
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 1:1520 THOMAS LAKE POINTE RD
Mailing Address - Street 2:#104
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1520 THOMAS LAKE POINTE RD
Practice Address - Street 2:#104
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2566
Practice Address - Country:US
Practice Address - Phone:763-482-2694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist