Provider Demographics
NPI:1396475927
Name:MARY T OUTPATIENT
Entity type:Organization
Organization Name:MARY T OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:TJOSVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-567-8951
Mailing Address - Street 1:1555 118TH LN NW STE 1
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7500
Mailing Address - Country:US
Mailing Address - Phone:763-219-7491
Mailing Address - Fax:
Practice Address - Street 1:11800 XEON BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-2061
Practice Address - Country:US
Practice Address - Phone:763-489-3638
Practice Address - Fax:763-647-3885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty