Provider Demographics
NPI:1811372782
Name:HALVERSON, DELORA 'LORA' (LPTA; DOR)
Entity Type:Individual
Prefix:
First Name:DELORA 'LORA'
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:LPTA; DOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LE SUEUR
Mailing Address - State:MN
Mailing Address - Zip Code:56058-2203
Mailing Address - Country:US
Mailing Address - Phone:507-665-8689
Mailing Address - Fax:507-665-0072
Practice Address - Street 1:621 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LE SUEUR
Practice Address - State:MN
Practice Address - Zip Code:56058-2203
Practice Address - Country:US
Practice Address - Phone:507-665-8689
Practice Address - Fax:507-665-0072
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1042225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant