Provider Demographics
NPI:1497080212
Name:WALIN, MARIANE LYN (PT, DPT, CIMT)
Entity Type:Individual
Prefix:
First Name:MARIANE
Middle Name:LYN
Last Name:WALIN
Suffix:
Gender:F
Credentials:PT, DPT, CIMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-0574
Mailing Address - Country:US
Mailing Address - Phone:612-200-0619
Mailing Address - Fax:612-844-9108
Practice Address - Street 1:18055 198TH AVE NW UNIT B161
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4926
Practice Address - Country:US
Practice Address - Phone:612-200-0619
Practice Address - Fax:612-844-9108
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00875211OtherMEDICARE RAILROAD
IL212623009Medicare PIN
IL212622011Medicare PIN
IL213392006Medicare PIN
IL209796011Medicare PIN
IL202845054Medicare PIN
IL212989012Medicare PIN
IL214708013Medicare PIN