Provider Demographics
NPI:1023062619
Name:BREKKE, TERI J (MPT)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:J
Last Name:BREKKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-5751
Mailing Address - Fax:701-364-5750
Practice Address - Street 1:1401 13TH AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3468
Practice Address - Country:US
Practice Address - Phone:701-364-5751
Practice Address - Fax:701-364-5750
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDHP62323OtherHEALTHPARTNERS #
ND51096Medicaid
MN6436OtherMN LIC #
NDHP62323OtherHEALTHPARTNERS #