Basic Information
| Provider Information | |||||||||
| NPI: | 1811200793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEROUCHEY | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 3111 124TH AVE NW | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554334572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634277300 | ||||||||
| FaxNumber: | 7634272802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 8516 | MN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.