Basic Information
| Provider Information | |||||||||
| NPI: | 1831440650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UGALDE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT-DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1660 HIGHWAY 100 SOUTH | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524566160 | ||||||||
| FaxNumber: | 9524566184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 HIGHWAY 100 SOUTH | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524566160 | ||||||||
| FaxNumber: | 9524566184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 04/03/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9157 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2081N0008X | 9157 | MN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Neuromuscular Medicine |
ID Information
| ID | Type | State | Issuer | Description | 650002921 | 01 | MN | MEDICARE PTAN | OTHER | C09200 | 01 | MN | GROUP PTAN | OTHER | C09271 | 01 | MN | MEDICARE PTAN | OTHER |