Provider Demographics
NPI:1699200626
Name:SMALL, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 FRANCE AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2356
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:
Practice Address - Street 1:5400 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55410-2356
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11429225100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation