Provider Demographics
NPI:1689095267
Name:RANSTROM, ADAIRE (MT-BC)
Entity Type:Individual
Prefix:
First Name:ADAIRE
Middle Name:
Last Name:RANSTROM
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-1902
Mailing Address - Country:US
Mailing Address - Phone:218-201-0199
Mailing Address - Fax:
Practice Address - Street 1:521 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1902
Practice Address - Country:US
Practice Address - Phone:218-201-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10653225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist