Provider Demographics
NPI:1265499818
Name:DERUITER, MARY ANN BURKE (PT)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:BURKE
Last Name:DERUITER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY ROAD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0716
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY ROAD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0716
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69D76BUOtherBCBS
6401919OtherMEDICA
HP43081OtherHEALTHPARTNERS