Basic Information
| Provider Information | |||||||||
| NPI: | 1922106913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMERSON | ||||||||
| FirstName: | MARIAH | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9055 SPRINGBROOK DR NW | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554335841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632361035 | ||||||||
| FaxNumber: | 7632361086 | ||||||||
| Practice Location | |||||||||
| Address1: | 6465 WAYZATA BLVD STE 315 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529937169 | ||||||||
| FaxNumber: | 9529930300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 05/01/2009 | ||||||||
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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 | 225100000X | 7790 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1922106913 | 05 | MN | MEDICAID |