Provider Demographics
NPI:1609295880
Name:PASS, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:PASS
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 1:11262 CTY RD 21
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MN
Mailing Address - Zip Code:55922
Mailing Address - Country:US
Mailing Address - Phone:608-769-6666
Mailing Address - Fax:
Practice Address - Street 1:11262 CTY RD 21
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MN
Practice Address - Zip Code:55922
Practice Address - Country:US
Practice Address - Phone:608-769-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1536225200000X
IA004850225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant