Provider Demographics
NPI:1285859066
Name:BAZELLA, JOAN MARLAYNE (PT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARLAYNE
Last Name:BAZELLA
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 1:115 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1837
Mailing Address - Country:US
Mailing Address - Phone:952-448-7036
Mailing Address - Fax:
Practice Address - Street 1:480 W 78TH ST
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4527
Practice Address - Country:US
Practice Address - Phone:952-906-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6B344LOOtherBCBS MN