Basic Information
| Provider Information | |||||||||
| NPI: | 1851706105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUDREAU | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3055 EAGANDALE PL APT 225 | ||||||||
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| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123662191 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8100 W 78TH ST. | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2014 | ||||||||
| LastUpdateDate: | 06/26/2014 | ||||||||
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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 | 2255A2300X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.