Provider Demographics
NPI:1801084140
Name:KROLL, ANTHONY (CPT, LMT, ERS)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KROLL
Suffix:
Gender:M
Credentials:CPT, LMT, ERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 WHITE BEAR AVE N
Mailing Address - Street 2:SUITE #202
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4466
Mailing Address - Country:US
Mailing Address - Phone:651-246-3873
Mailing Address - Fax:
Practice Address - Street 1:3609 WHITE BEAR AVE N
Practice Address - Street 2:SUITE #202
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-4466
Practice Address - Country:US
Practice Address - Phone:651-246-3873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist