Provider Demographics
NPI:1992854061
Name:PROVENCHER, MARISA MAE (PT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:MAE
Last Name:PROVENCHER
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 1:1095 HIGHWAY 15 S
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-5000
Mailing Address - Country:US
Mailing Address - Phone:320-234-5000
Mailing Address - Fax:
Practice Address - Street 1:1095 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-5000
Practice Address - Country:US
Practice Address - Phone:320-234-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist