Provider Demographics
NPI:1467620039
Name:DANIELSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DANIELSON
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 1:1696 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-5050
Mailing Address - Country:US
Mailing Address - Phone:612-597-2975
Mailing Address - Fax:763-682-1668
Practice Address - Street 1:1696 7TH ST NW
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-5050
Practice Address - Country:US
Practice Address - Phone:612-597-2975
Practice Address - Fax:763-682-1668
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN383602900Medicaid