Provider Demographics
NPI:1689953036
Name:ULLEDAHL, TIMOTHY LEE (PTA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:ULLEDAHL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 E BISMARCK EXPY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6708
Mailing Address - Country:US
Mailing Address - Phone:701-323-5222
Mailing Address - Fax:701-323-5867
Practice Address - Street 1:1833 EAST BISMARCK EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58554
Practice Address - Country:US
Practice Address - Phone:701-323-5222
Practice Address - Fax:701-323-5867
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant