Provider Demographics
NPI:1962498238
Name:HULZEBOS, SHAWNA L (PT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:L
Last Name:HULZEBOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:L
Other - Last Name:RUCKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1720 S CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2129
Mailing Address - Country:US
Mailing Address - Phone:605-334-5630
Mailing Address - Fax:605-332-5327
Practice Address - Street 1:1530 ROWE AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-9700
Practice Address - Country:US
Practice Address - Phone:507-372-2232
Practice Address - Fax:605-332-5327
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64-04248OtherMEDICA
MN31682OtherSIOUX VALLEY HEALTH PLANS
MNPT6816OtherDAKOTACARE
MN1982879OtherARAZ
MN64-04246OtherMEDICA
MN64-05335OtherMEDICA
MN64-04247OtherMEDICA
MN64-04245OtherMEDICA
MN254T9RUOtherBLUE CROSS BLUE SHIELD MN
MN8569OtherAVERA HEALTH PLANS