Provider Demographics
NPI:1922106913
Name:EMERSON, MARIAH ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ELIZABETH
Last Name:EMERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9055 SPRINGBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5841
Mailing Address - Country:US
Mailing Address - Phone:763-236-1035
Mailing Address - Fax:763-236-1086
Practice Address - Street 1:6465 WAYZATA BLVD STE 315
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1730
Practice Address - Country:US
Practice Address - Phone:952-993-7169
Practice Address - Fax:952-993-0300
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1922106913Medicaid
1922106913Medicare Oscar/Certification
1922106913Medicare NSC
MN1922106913Medicaid
1922106913Medicare PIN