Provider Demographics
NPI:1326663030
Name:MEEHAN, KIEBORT ANNAS (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KIEBORT
Middle Name:ANNAS
Last Name:MEEHAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 3RD ST N
Mailing Address - Street 2:STE 105
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:955 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55115-1847
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2020001225100000X
MN12193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist