Provider Demographics
NPI:1306369319
Name:PROM, DANIELLE (DPT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:PROM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10653 WAYZATA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1543
Mailing Address - Country:US
Mailing Address - Phone:952-224-1919
Mailing Address - Fax:
Practice Address - Street 1:701 HORIZON CIR
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3051
Practice Address - Country:US
Practice Address - Phone:218-879-6956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9184225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist