Provider Demographics
NPI:1629124540
Name:HATLESTAD, STEPHANIE JO (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:HATLESTAD
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 1:3601 MINNESOTA DR
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5281
Mailing Address - Country:US
Mailing Address - Phone:952-851-8200
Mailing Address - Fax:
Practice Address - Street 1:3601 MINNESOTA DR
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5281
Practice Address - Country:US
Practice Address - Phone:952-851-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087H8HAOtherBLUE CROSS INDIVIDUAL ID
MN1024610OtherPREFFERED ONE ID
MN6B478OROtherBLUE CROSS GROUP ID
MN087H8HAOtherBLUE CROSS INDIVIDUAL ID