Basic Information
Provider Information | |||||||||
NPI: | 1891801486 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STOCK | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAURICH | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6465 WAYZATA BLVD | ||||||||
Address2: | SUITE 900 | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554261728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525125600 | ||||||||
FaxNumber: | 9525125650 | ||||||||
Practice Location | |||||||||
Address1: | 6363 FRANCE AVE S | ||||||||
Address2: | SUITE 404 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554352129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529274525 | ||||||||
FaxNumber: | 9529277554 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 07/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6730 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 969991030949 | 01 |   | PREFERREDONE | OTHER | 6405865 | 01 |   | MEDICA | OTHER | HP55103 | 01 |   | HEALTHPARTNERS | OTHER | 261P0ST | 01 |   | BLUECROSS BLUESHIELD | OTHER |