Provider Demographics
NPI:1821345406
Name:LOBERG, KELI JO
Entity Type:Individual
Prefix:
First Name:KELI
Middle Name:JO
Last Name:LOBERG
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 1:11269 JEFFERSON HWY N STE 200
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3165
Mailing Address - Country:US
Mailing Address - Phone:763-236-0780
Mailing Address - Fax:
Practice Address - Street 1:11269 JEFFERSON HWY N STE 200
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3165
Practice Address - Country:US
Practice Address - Phone:763-236-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist