Provider Demographics
NPI:1124129598
Name:FERN, MICHELLE MARIE (RPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:FERN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 FREMONT AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 MINNESOTA AVE
Practice Address - Street 2:THERAPY CONNECTIONS FOR KIDS
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1781
Practice Address - Country:US
Practice Address - Phone:651-206-3697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5301225100000X
MN5402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41810700Medicaid
MN77G76FEOtherBCBS