Provider Demographics
NPI:1639459431
Name:BLAINE, KALLIE J (DPT)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:J
Last Name:BLAINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:
Other - Last Name:TELLEFSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1574 154TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4788
Mailing Address - Country:US
Mailing Address - Phone:763-443-8108
Mailing Address - Fax:
Practice Address - Street 1:1574 154TH AVE NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4788
Practice Address - Country:US
Practice Address - Phone:763-443-8108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1879002Medicare PIN