Provider Demographics
NPI:1891998035
Name:MINNETONKA PEDIATRIC THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:MINNETONKA PEDIATRIC THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAUMGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP/COM
Authorized Official - Phone:763-595-0812
Mailing Address - Street 1:15600 36TH AVE N STE 120
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3687
Mailing Address - Country:US
Mailing Address - Phone:763-595-0812
Mailing Address - Fax:763-595-0824
Practice Address - Street 1:15600 36TH AVE N STE 120
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3687
Practice Address - Country:US
Practice Address - Phone:763-595-0812
Practice Address - Fax:763-595-0824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225100000X, 225X00000X, 235Z00000X
225XP0200X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323915000Medicaid