Basic Information
| Provider Information | |||||||||
| NPI: | 1831135946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELTY | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | CHARLOTTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOEBERNIK | ||||||||
| OtherFirstName: | INGRID | ||||||||
| OtherMiddleName: | CHARLOTTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7635200355 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880811 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2973 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | HP11689 | 01 | HEALTH PARTNERS | OTHER | 90D36WE | 01 | BCBS MINNESOTA | OTHER | 6401265 | 01 | MEDICA | OTHER |