Basic Information
| Provider Information | |||||||||
| NPI: | 1891796124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANSELOW | ||||||||
| FirstName: | JONI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6933 BLACK DUCK DR | ||||||||
| Address2: | |||||||||
| City: | LINO LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550141319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514268830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4010 W 65TH ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522852840 | ||||||||
| FaxNumber: | 9522852830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2169 | MN | Y | Other Service Providers | Specialist |
No ID Information.