Basic Information
| Provider Information | |||||||||
| NPI: | 1184642373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAHL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15700 37TH AVE N STE 220 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15700 37TH AVE N STE 220 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685201 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 20878 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1184642373 | 01 | FL | CIGNA | OTHER |