Provider Demographics
NPI:1275674137
Name:EWALD, BETTY J (PT)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:J
Last Name:EWALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:J
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:912 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLEFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56653-9357
Mailing Address - Country:US
Mailing Address - Phone:218-278-6634
Mailing Address - Fax:218-278-6637
Practice Address - Street 1:912 MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLEFORK
Practice Address - State:MN
Practice Address - Zip Code:56653-9357
Practice Address - Country:US
Practice Address - Phone:218-278-6634
Practice Address - Fax:218-278-6637
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64-11268OtherMEDICA