Provider Demographics
NPI:1821193681
Name:YOUNGDAHL, RODERICK LAINE (PT)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:LAINE
Last Name:YOUNGDAHL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 240
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1198
Practice Address - Country:US
Practice Address - Phone:952-456-7400
Practice Address - Fax:952-456-7401
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist