Provider Demographics
NPI:1396376042
Name:HEBERLING, MARY JO
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:HEBERLING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LUELLA ST
Mailing Address - Street 2:
Mailing Address - City:WATKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55389-1012
Mailing Address - Country:US
Mailing Address - Phone:320-764-2300
Mailing Address - Fax:
Practice Address - Street 1:410 LUELLA ST
Practice Address - Street 2:
Practice Address - City:WATKINS
Practice Address - State:MN
Practice Address - Zip Code:55389-1012
Practice Address - Country:US
Practice Address - Phone:320-765-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1045225100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist