Provider Demographics
NPI:1477640613
Name:FUNCTIONAL INTEGRATED THERAPY, LTD
Entity Type:Organization
Organization Name:FUNCTIONAL INTEGRATED THERAPY, LTD
Other - Org Name:FUNCTIONAL KIDS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:651-770-8884
Mailing Address - Street 1:2495 MAPLEWOOD DRIVE
Mailing Address - Street 2:SUITE 313
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1913
Mailing Address - Country:US
Mailing Address - Phone:651-770-8884
Mailing Address - Fax:651-770-8151
Practice Address - Street 1:2495 MAPLEWOOD DRIVE
Practice Address - Street 2:SUITE 313
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1913
Practice Address - Country:US
Practice Address - Phone:651-770-8884
Practice Address - Fax:651-770-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100591261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0007336046OtherAETNA
MN133343OtherCHOICE PLUS/PATIENT CHOIC
MN28D39FUOtherBLUE CROSS BLUE SHIELD
MN6401782OtherMEDICA
MN670043800Medicaid
MNJ053OtherUCARE GROUP
MN18905OtherPREFERRED ONE
MN181389OtherUCARE INDIVIDUAL
MN36655OtherST PAUL ELECTRICAL WORKER
MN75732OtherHEALTH PARTNERS
MN6401782OtherMEDICA
MN75732OtherHEALTH PARTNERS