Provider Demographics
NPI:1952940892
Name:CARPENTER, CHRISTA MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:MARIE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9184 W 126TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1182
Mailing Address - Country:US
Mailing Address - Phone:952-393-2846
Mailing Address - Fax:
Practice Address - Street 1:1909 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-2047
Practice Address - Country:US
Practice Address - Phone:952-473-1261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106132225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist