Provider Demographics
NPI:1205890902
Name:LAVERNE, SANDRA (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:LAVERNE
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 1:2835 W SAINT GERMAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4743
Mailing Address - Country:US
Mailing Address - Phone:320-259-4151
Mailing Address - Fax:320-259-5707
Practice Address - Street 1:2835 W SAINT GERMAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4743
Practice Address - Country:US
Practice Address - Phone:320-259-4151
Practice Address - Fax:320-259-5707
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN5779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6405071OtherMEDICA PROVIDER ID
MN03S81LAOtherBCBS PROVIDER ID
MN41163580956301B011OtherCHAMPA PROVIDER ID