Provider Demographics
NPI:1013638659
Name:PEARSON, GRETCHEN LYNN (CMT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:LYNN
Last Name:PEARSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1139
Mailing Address - Country:US
Mailing Address - Phone:612-399-6322
Mailing Address - Fax:
Practice Address - Street 1:1717 2ND ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1139
Practice Address - Country:US
Practice Address - Phone:612-399-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79867225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA79867OtherCERTIFIED MASSAGE THERAPIST