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Organization
MARY T OUTPATIENT
Active
Organization
MARY T OUTPATIENT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JASON TJOSVOLD (CHIEF ADMINISTRATIVE OFFICER)
(763) 567-8951
Entity
Organization
Contact information
Practice address
11800 XEON BLVD NW, COON RAPIDS, MN 55448-2061
(763) 489-3638
(763) 647-3885
Mailing address
1555 118TH LN NW STE 1, COON RAPIDS, MN 55448-7500
(763) 219-7491
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
NULL
225100000X
Physical Therapist
Primary
—
—
225X00000X
Occupational Therapist
—
NULL
225X00000X
Occupational Therapist
—
—
Other
Enumeration date
06/15/2022
Last updated
06/24/2022
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