Provider Demographics
NPI:1831162551
Name:ETTER, LAREE L (MED, MPT)
Entity type:Individual
Prefix:
First Name:LAREE
Middle Name:L
Last Name:ETTER
Suffix:
Gender:F
Credentials:MED, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 MINNEHAHA AVE W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1033
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:66 E SAINT MARIE ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-2646
Practice Address - Country:US
Practice Address - Phone:218-313-1387
Practice Address - Fax:218-999-0612
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid
OTH000Medicare UPIN
IAENROLLEDMedicaid