Provider Demographics
NPI:1649570771
Name:DENNIE, PHILIP CHARLES (ATC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CHARLES
Last Name:DENNIE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:PHIL
Other - Middle Name:
Other - Last Name:DENNIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:5092 MORRIS THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6001 DODGE ST # FH024
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68182-1102
Practice Address - Country:US
Practice Address - Phone:218-310-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer