Provider Demographics
NPI:1598728545
Name:LEGO, CAROL JEAN (PT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:LEGO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 E 28TH ST
Mailing Address - Street 2:SUITE 460
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1139
Mailing Address - Country:US
Mailing Address - Phone:612-874-8919
Mailing Address - Fax:612-874-8137
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1935
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-339-2041
Practice Address - Fax:612-339-2042
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN40B34LEOtherBC INDIV PROV ID
MN6402026OtherMEDICA INDIV PROV ID