Provider Demographics
NPI:1508388828
Name:DVORAK, DEIRDRE M
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:M
Last Name:DVORAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEIRDRE
Other - Middle Name:M
Other - Last Name:ARNOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4501 PARK GLEN RD APT 247
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty