# MARY T OUTPATIENT

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1396475927
- **Authorized official:** JASON TJOSVOLD (CHIEF ADMINISTRATIVE OFFICER)
- **Authorized official phone:** (763) 567-8951

## Contact information

- **Practice address:** 11800 XEON BLVD NW, COON RAPIDS, MN 55448-2061
- **Practice address phone:** (763) 489-3638
- **Practice address fax:** (763) 647-3885
- **Mailing address:** 1555 118TH LN NW STE 1, COON RAPIDS, MN 55448-7500
- **Mailing address phone:** (763) 219-7491

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | — | NULL | Yes |
| 225100000X | Physical Therapist | — | — | Yes |
| 225X00000X | Occupational Therapist | — | NULL | — |
| 225X00000X | Occupational Therapist | — | — | — |

## Other

- **Enumeration date:** 06/15/2022
- **Last updated:** 06/24/2022